Damas Hospital Snf
Inspection history, citations, penalties and survey trends for this long-term care facility in Ponce, PR.
- Location
- 2213 Ponce By Pass, Ponce, PR 00717
- CMS Provider Number
- 405023
- Inspections on file
- 17
- Latest survey
- March 5, 2026
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Damas Hospital Snf during CMS and state inspections, most recent first.
Surveyors found that the facility did not accommodate the food preferences and needs of three residents, including not providing traditionally prepared coffee, serving unpalatable unsweetened hot cereal, and offering dry meat that was not palatable. These actions resulted in residents not receiving food in a form designed to meet their individual requirements.
Surveyors identified that chicken was held at an insufficient temperature of 132°F instead of the required 165°F for poultry. The meat freezer had an uneven, broken floor with mold and ice present, and the holding racks inside the freezer were rusted. These issues demonstrate noncompliance with professional food service safety standards.
Surveyors observed that a resident's refrigerator contained an unlabeled yogurt and ice cream, indicating the facility did not follow its policy for safe and sanitary storage of foods brought in by family or visitors.
Surveyors identified failures in infection prevention, including improper temperature monitoring in medical supply storage, lack of documentation of corrective actions, dusty air conditioning grills in resident rooms, and repeated lapses in hand hygiene by staff during wound care and medication administration. These deficiencies affected all residents receiving care.
An inspection found that air conditioning inlet grilles in three rooms were dusty, despite facility policy requiring regular cleaning and filter replacement by physical plant and cleaning staff.
Surveyors identified widespread environmental deficiencies affecting resident rooms, including damaged furniture, unsafe bathroom grab bars, mold, deteriorated flooring, and unclean conditions. These issues compromised the safety, cleanliness, and comfort of the living environment for multiple residents.
A resident with a history of sleep apnea and CPAP use was not fully assessed upon admission, resulting in the omission of her diagnosis and equipment needs from the initial care plan. The facility did not complete a timely comprehensive MDS assessment to identify all of the resident's diagnoses and needs.
A resident admitted for knee replacement with a history of sleep apnea and CPAP use did not have her respiratory care needs included in the baseline care plan within 48 hours of admission. The resident's CPAP machine was not functioning, and staff were not notified of her diagnosis or equipment needs, resulting in the absence of a documented plan to address her respiratory care.
A resident with a history of sleep apnea brought her own CPAP machine to the facility after a knee replacement, but staff were not informed of her diagnosis or need for the device. When the resident found her CPAP was not working, the facility was unable to provide appropriate respiratory care due to lack of information, necessary parameters, and suitable equipment.
Surveyors found that the facility did not maintain an effective pest control program, as evidenced by a spider observed behind curtains in a resident's room during an inspection with the Physical Plant Director.
The facility failed to maintain sufficient nursing staff when an LPN was reassigned from the SNF to a hospital ward, leaving the SNF short-staffed. The required staffing for 19 residents was three LPNs and two RNs, but only two LPNs were available for direct care. Despite a consistent staffing requirement of 4.5 hours per resident, the facility did not adjust staffing based on actual needs. Documentation showed 26 instances of staff reassignment, highlighting a pattern of inadequate staffing adjustments.
The facility failed to ensure all SNF employees completed required abuse and neglect training, with 7 out of 22 nursing personnel not finishing all modules of the Hand in Hand training. This training is crucial for staff to protect residents' rights to be free from mental abuse. The inconsistency in training completion was partly due to the e-learning system allowing modules to be completed at different times. An interview with the Associate DON confirmed the training was provided annually, but not all employees completed it in a timely manner.
The facility did not provide Residents Rights training to its SNF employees, as revealed by a review of 22 credential files and interviews with the Associate DON. None of the nursing personnel had received the necessary training, indicating a failure to ensure staff were knowledgeable about protecting residents' rights.
The facility did not ensure effective staff training in critical areas such as abuse, neglect, dementia management, and Residents' Rights. A review of 22 credential files revealed that several nursing personnel did not complete required training modules, including the Hand in Hand series and Pain Management. This lack of comprehensive training compromises the staff's ability to respond appropriately to protect residents' rights.
The facility failed to ensure all SNF employees completed required abuse and neglect training, with 7 out of 22 staff missing key modules. Training was provided via e-learning, but some employees did not complete all modules necessary for their roles, leading to a deficiency in protecting residents from mental abuse.
The facility failed to conduct an exhaustive screening process for an LPN transferred to the SNF, who had a history of abuse and neglect incidents. Despite being reoriented on protocols, the LPN was transferred without rigorous screening, as the facility's process for internal transfers is less thorough than for new hires. This led to the LPN being involved in a suspected abuse and neglect incident.
The facility failed to ensure all SNF employees completed required abuse and neglect training, with 7 out of 22 nursing personnel not finishing crucial modules. Training was primarily through e-learning, leading to incomplete education. The facility also lacked coordination with the Quality Assessment Performance Improvement Program to protect residents' rights during suspected abuse incidents.
A facility failed to report an incident of neglect involving a resident receiving rehabilitation for a left knee replacement. The resident felt neglected when a nurse did not stay nearby to assist with her hygiene needs, leading to distress and refusal of physical therapy. An investigation confirmed neglect, but the facility did not notify the state agency within the required time frame.
The facility failed to follow infection control precautions during food distribution. Kitchen personnel did not check if residents were in their rooms before removing lunch trays from the food warmer cart, leading to trays being returned to the cart after potential exposure to room surfaces. The infection control officer confirmed this practice was incorrect.
The facility failed to ensure the Infection Preventionist attended multiple QAPI committee meetings. The QAPI employee presented the infection control report on behalf of the Infection Preventionist, but there was no evidence of the Infection Preventionist's direct participation as required.
The facility failed to maintain an infection prevention and control program, as evidenced by multiple observations of staff not adhering to proper hand hygiene, disinfection protocols, and safe storage practices. These lapses were observed during medication administration, meal service, and blood glucose monitoring, potentially increasing the risk of infections among residents.
The facility failed to ensure reasonable accommodation for residents, as observed during a tour with the Engineering Director. Issues included loose brake frames on wheelchairs, rusted chairs in occupational therapy, improper storage of linen and medical equipment, and an overflowing biomedical waste room.
The facility failed to ensure residents received services with reasonable accommodation of their needs and preferences. Clinical staff transferred a resident using a crane, invading the space of another resident in the same room and causing discomfort.
The facility failed to maintain a safe, clean, comfortable, and homelike environment. The bathroom lighting fixture did not provide adequate illumination in the shower area, and there was an accumulation of dust particles behind the headrests of bed platforms in residents' sleeping areas.
The facility failed to maintain an effective pest control program, resulting in the presence of spiders, spider webs, and ants in multiple rooms, as well as signs of an anthill forming in one room.
The facility failed to maintain the dignity of a resident with urine incontinence by using a visible blue medical surgical pad on her wheelchair during meal times. The resident was observed touching the pad while eating, which compromised her dignity. The nursing supervisor acknowledged that a more discreet fabric pad could be used.
A nurse performed a Dextrostix test on a resident without fully closing the privacy curtain, allowing relatives of another resident in the same room to see the procedure, thus compromising the resident's privacy.
A resident with a diagnosis of Fracture of Left Femur was observed eating lunch without assistance despite periods of disorientation and distraction, resulting in the resident consuming only about 60% of her meal. No staff were observed supervising or cueing the resident during these periods.
The facility failed to provide necessary care and services for a resident with a Fracture of Left Femur who was observed disoriented and incontinent. The resident was seen touching her back area and pulling a medical pad while eating lunch, but no personnel assisted or checked if she needed perineal care or a change of incontinence items.
The facility failed to meet a resident's food preferences during lunch service. The resident expressed dissatisfaction with the main dish and was not offered a substitution by nursing personnel, despite the availability of an alternate menu. The nursing supervisor confirmed that it is the staff's responsibility to ensure residents are satisfied with their meals.
Failure to Accommodate Resident Food Preferences and Needs
Penalty
Summary
The facility failed to provide food that met the individual needs and preferences of three residents, as observed during dining and confirmed through staff interviews and policy review. One resident who did not consume instant coffee and preferred traditionally prepared coffee was not provided with their preferred option. Another resident was served unsweetened hot cereal, which was not palatable and could not be eaten due to its flavor. A third resident reported that the meat served was dry and not palatable according to their preference. These findings demonstrate that the facility did not accommodate resident allergies, intolerances, and preferences as required, resulting in residents not receiving food in a form designed to meet their individual needs.
Food Service Safety Deficiencies Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food service operations. Chicken was found being held at 132 degrees Fahrenheit on the serving line, which does not meet the required holding temperature of 165 degrees Fahrenheit for poultry. Additionally, the meat freezer floor was noted to be uneven and had broken cement at the entrance, which allowed mold and ice to develop. The holding racks inside the meat freezer were also observed to have rust on the tubing. These findings indicate that the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as required.
Failure to Label and Store Visitor-Brought Food Items Properly
Penalty
Summary
The facility failed to comply with its policy regarding the use and storage of foods brought in by family and other visitors for residents. During an observation of the residents' refrigerator, surveyors found an unlabeled yogurt and ice cream. This indicates that the facility did not ensure proper labeling and storage of these food items as required by their policy.
Infection Control Lapses in Temperature Monitoring, Hand Hygiene, and Environmental Cleaning
Penalty
Summary
The facility failed to adhere to standard infection prevention and control practices, as evidenced by multiple deficiencies observed during the survey. In the medical-surgical supply storage area, temperatures were consistently recorded below the facility's policy parameters of 70°F to 75°F, with readings ranging from 66.1°F to 69.5°F over several months. Despite these deviations, there was no documentation of corrective actions taken by staff. Additionally, the air conditioning inlet grill compartments in several resident rooms were found to be dusty, indicating a lack of proper cleaning as required by facility procedures. During wound care procedures, an orthopedic technician did not perform hand hygiene between glove changes or before applying wound dressings, and there was no facility policy guiding wound management by this staff member. Furthermore, during medication passes, registered nurses failed to perform hand hygiene in multiple observed opportunities. These lapses in infection control practices could affect all residents receiving care in the facility.
Failure to Maintain Clean Air Conditioning Inlet Grilles
Penalty
Summary
During an inspection conducted on 03/27/2025, it was found that the facility failed to maintain proper sanitation of the air conditioning inlet grille compartments in three resident rooms. Observations made during a walkthrough with the Physical Plant Manager revealed that the inlet grilles in rooms #309, #310, and #311 were dusty. The facility's policy, last updated in 02/2025, requires physical plant personnel to replace air duct filters monthly and cleaning staff to clean the grilles, but these procedures were not followed as evidenced by the dust accumulation.
Environmental Deficiencies Compromise Resident Comfort and Safety
Penalty
Summary
Surveyors observed multiple deficiencies in the physical environment of the facility during a site visit, noting that 8 out of 9 resident rooms inspected failed to meet standards for a safe, clean, comfortable, and homelike environment. Specific findings included nightstands with exposed plastic covers, deteriorated armrests on armchairs, an uneven table tray, the absence of a cord to operate a light, and unsafe, loose bathroom grab bars. Additional issues included mold in a bathroom faucet area, deteriorated flooring, detached and deteriorated floor baseboards, and areas behind chairs and beds littered with dirt and trash. These observations were made in the presence of the Physical Plant Director and were directly witnessed by surveyors during their inspection. No information was provided regarding the medical history or condition of the residents in the affected rooms at the time of the deficiency.
Failure to Complete Timely Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for one resident. Upon admission, the resident, who had a history of sleep apnea and used a CPAP machine since 2018, was not fully assessed for all diagnoses and needs. The resident reported that her CPAP machine was brought from home and that staff were informed of her diagnosis and equipment requirement. However, the initial care plan did not include the diagnosis of sleep apnea or the need for a CPAP, and the comprehensive assessment did not identify all of the resident's diagnoses and needs.
Failure to Develop Baseline Care Plan for Respiratory Needs Within 48 Hours of Admission
Penalty
Summary
A deficiency was identified when a resident admitted for a left artificial knee replacement, who also had a history of sleep apnea and required a CPAP machine, did not have her respiratory care needs addressed in the baseline care plan within 48 hours of admission. The resident reported that she had been using a CPAP machine since 2018 and brought her own device to the facility, but the nursing or medical staff were not notified of her diagnosis or the need for the machine. On the night of March 26, the resident attempted to use her CPAP machine and found it was not working. Upon review of the resident's medical record, it was found that the baseline care plan did not include any interventions or plans for respiratory care or the use of the CPAP machine. The Respiratory Therapy Director confirmed that their department would provide care once a medical order or nursing recommendation was received, but in this case, there was a lack of information and appropriate equipment. The facility failed to conduct and document a baseline care plan within the required 48-hour window that addressed the resident's immediate respiratory needs.
Failure to Provide Needed Respiratory Care for Resident Using CPAP
Penalty
Summary
A deficiency occurred when a resident with a history of sleep apnea, who had been using a CPAP machine since 2018, was admitted following a knee replacement. The resident brought her own CPAP machine to the facility, but neither nursing nor medical staff were notified of her diagnosis or her need for the device. The resident discovered her CPAP machine was not working when she attempted to use it, and there was no prior assessment or documentation of her respiratory needs by facility staff. Interviews with the Director and Supervisor of Respiratory Therapy revealed that the facility's process for providing respiratory care depends on receiving a medical order or nursing recommendation. In this case, the staff did not have the necessary parameters to set up a replacement CPAP machine, and the equipment available did not match the resident's preferences. Additionally, the resident's pulmonologist could not provide the required settings because the resident had not attended a follow-up visit for two years, and a new sleep study would be needed. As a result, the facility was unable to provide the specialized respiratory care required for the resident.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
Surveyors observed that the facility failed to maintain an effective pest control program, as evidenced by the presence of a spider behind the curtains in a resident's room. This observation was made during a walkthrough of resident rooms with the Physical Plant Director. The deficiency was identified based on direct observation and staff interview, indicating that the facility was not free of pests at the time of the survey. No additional information about the resident's medical history or condition was provided in the report.
Staffing Deficiency Due to Reassignment of LPN
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by an incident on 10/20/2024. On this day, the Director of Nursing (DON) and the Nursing Supervisor confirmed that one Licensed Practical Nurse (LPN) was reassigned from the Skilled Nursing Facility (SNF) to the hospital's ninth-floor medicine ward, leaving the SNF short-staffed. The staffing requirement for a census of 19 residents was calculated to be three LPNs and two Registered Nurses (RNs), but only two LPNs were available to provide direct care duties such as vital signs measurement, bathing assistance, and feeding assistance. The DON suggested that the staffing calculation might have been overestimated, but no clear explanation was provided for the discrepancy in staffing needs. The report also highlights that the facility's monthly nursing staffing summary for 2024 consistently showed a required staffing level of 4.5 hours per resident, regardless of the fluctuating census between 9 and 19 residents. This inconsistency suggests a lack of adjustment in staffing levels based on actual resident needs and census changes. The Nursing Supervisor acknowledged that the SNF must comply with the Payroll Based Journal requirement, which mandates the collection of audited and verifiable staffing data to be reported to CMS. Despite this, the reassignment of an LPN on 10/20/2024 was not reflected in the staffing categorization. Additionally, documentation revealed that nursing personnel from the SNF were reassigned to other hospital areas on 26 occasions throughout the year, always during the 7-3 shift. The incident on 10/20/2024 was the only time this occurred on a weekend. The Nursing Supervisor emphasized the importance of maintaining adequate staffing levels to meet the rehabilitation goals of the SNF, which differ from those of an acute care ward. However, the reassignment of staff without adjusting the categorization or staffing calculations indicates a failure to ensure sufficient nursing staff to meet resident needs.
Incomplete Staff Training on Abuse and Neglect
Penalty
Summary
The facility failed to ensure that all employees of the Skilled Nursing Facility (SNF) completed the required abuse and neglect training and the Hand in Hand training. During a review of 22 credential files, it was found that 7 out of 22 nursing personnel did not complete all modules of the Hand in Hand training. Specifically, these employees did not complete Module 4, 'Being with a person with Dementia: Making a Difference,' and Module 5, 'Preventing and Responding to Abuse.' This training was intended to ensure that employees are knowledgeable and can react appropriately to protect residents' rights to be free from mental abuse. The report details specific instances where employees either did not complete the required modules or completed them in a different setting, such as a hospital, before being transferred to the SNF. For example, one employee completed the modules in a hospital setting before being transferred to the SNF, while another employee completed some modules in the SNF but not all. The training was conducted through an e-learning computer system, allowing personnel to complete modules at different times throughout the year, which may have contributed to the inconsistency in training completion. An interview with the Associate Director of Nursing (DON) revealed that the facility provides education related to abuse and neglect through an e-learning system and conducts the Hand in Hand training annually. However, the facility did not ensure that all employees completed the training in a timely and sequential manner, leading to a deficiency in staff preparedness to handle situations involving abuse and neglect effectively.
Failure to Provide Residents Rights Training
Penalty
Summary
The facility failed to provide Residents Rights training to all employees of the Skilled Nursing Facility (SNF), as determined through a Credential file Review (CFR) and interviews with the Associate Director of Nursing (DON). During a review of 22 credential files on October 30, 2024, it was found that none of the 22 nursing personnel working in the SNF had received the required Residents Rights training. This deficiency indicates that the facility did not ensure its employees were knowledgeable about how to react and respond appropriately to protect the residents' rights.
Deficient Staff Training in Key Areas
Penalty
Summary
The facility failed to ensure an effective training program for all staff, which includes essential topics such as abuse, neglect, exploitation, misappropriation of residents' property, dementia management, Residents' Rights, and the Hand in Hand training series. This deficiency was identified during a review of 22 credential files, where it was found that 7 out of 22 nursing personnel did not complete the Hand in Hand training, 4 out of 22 did not complete Pain Management training, and 4 out of 22 did not complete Resident Experience training. The facility also failed to provide all employees with comprehensive training on abuse and neglect, Pain Management, and the Hand in Hand training series, which is crucial for ensuring that employees are knowledgeable and can respond appropriately to protect residents' rights.
Incomplete Training on Abuse Prevention in SNF
Penalty
Summary
The facility failed to ensure that all employees of the Skilled Nursing Facility (SNF) completed the required abuse and neglect and Hand in Hand training modules. This deficiency was identified during a review of 22 credential files, where it was found that 7 employees did not complete all the necessary training modules. Specifically, these employees did not complete Module 4, 'Being with a person with Dementia: Making a Difference,' and Module 5, 'Preventing and Responding to Abuse,' which are crucial for ensuring that staff can appropriately protect residents from mental abuse. The review revealed that the training was provided through an e-learning system, allowing employees to complete modules at their convenience throughout the year. However, the records showed that some employees completed the modules in different settings, such as hospital settings, before being transferred to the SNF. Despite having completed some modules, the employees did not complete the full series required for their roles in the SNF, indicating a gap in the training process and oversight. During an interview with the Associate Director of Nursing (DON), it was confirmed that the facility provides education on abuse and neglect through e-learning annually and had conducted in-person training in September 2024. However, the failure to ensure all employees completed the necessary training modules in a timely manner resulted in a deficiency in protecting residents' rights to be free from mental abuse.
Inadequate Screening Process for Transferred LPN
Penalty
Summary
The facility failed to maintain an exhaustive screening process before assigning an employee to provide direct care to residents, as identified in two out of seven complaints investigated. The facility's policy on abuse and neglect, effective since May 2023, mandates thorough screening of potential employees for any history of abuse and neglect. However, an incident reported on 10/20/2024 involved an LPN who had previously been involved in two incidents related to abuse and neglect in the maternity ward in 2018 and 2023. Despite being reoriented on abuse and neglect protocols, this LPN was transferred to the Skilled Nursing Facility (SNF) in June 2024 without a rigorous screening process. The Director of Nursing (DON) acknowledged that the LPN's past incidents were considered before the transfer, but the SNF Nursing Supervisor was not consulted or informed about the LPN's history. The Human Resource Director admitted that the screening process for staff transferring within the same hospital is less rigorous than for new hires, as the facility honors seniority and continuous employment. This discrepancy in the screening process contributed to the deficient practice of allowing an employee with a history of non-compliance with abuse and neglect protocols to provide direct care to residents.
Incomplete Training and Lack of Coordination in Abuse Prevention
Penalty
Summary
The facility failed to ensure that all employees of the Skilled Nursing Facility (SNF) completed the required abuse and neglect training and the Hand in Hand training. During a review of 22 Credential file Reviews (CFR), it was found that 7 out of 22 nursing personnel did not complete the Hand in Hand training modules 4 and 5, which are crucial for understanding dementia care and preventing and responding to abuse. The training was provided through an e-learning system, allowing personnel to complete modules at their convenience, but this led to incomplete training for some staff members. The report highlights that the facility did not provide the Hand in Hand training series in a timely and sequential manner, resulting in employees lacking the necessary knowledge to protect residents' rights effectively. Additionally, the facility failed to ensure that all employees acquired the knowledge to react and respond appropriately to protect residents' rights through abuse and neglect training. Interviews with the Associate Director of Nursing (DON) revealed that while some training was provided in person in September 2024, the e-learning system was the primary method for delivering this education. Furthermore, the facility did not establish and maintain communication and coordination with the Quality Assessment Performance Improvement Program to protect residents' rights when alleged incidents of abuse and neglect were suspected, investigated, and managed. This lack of coordination was noted during a complaint investigation survey conducted by Medicare Division Surveyors and Federal surveyors. The coordinator of resident experience and complaint management officer reported directly to the administration regarding complaints and resident satisfaction, but there was no evidence of a systematic approach to addressing these issues.
Failure to Report Neglect Incident Timely
Penalty
Summary
The facility failed to report an alleged incident of neglect involving a female resident who was receiving rehabilitation services for a left knee replacement. On April 29, 2024, a nurse took the resident to the shower but did not stay nearby to assist with her hygiene needs. The resident, who required minimal assistance, felt neglected and expressed her distress to her husband. This incident led to the resident feeling sad and anxious, causing her to refuse physical therapy and fear calling for assistance for other needs. The facility's policy required such incidents to be reported to the state agency, but it did not specify the time frame for reporting. The facility activated the abuse and neglect protocol and formed an Ad Hoc committee to investigate the incident on May 2, 2024. The committee determined that neglect had occurred and informed the facility administrator on May 6, 2024. Despite this, the administrator did not notify the state agency or any local entity. A phone call was made to the state Medicare division office on May 9, 2024, but it did not specify the findings of the Ad Hoc committee. This failure to report the incident within the required time frame constitutes a deficiency in the facility's compliance with state regulations.
Failure to Follow Infection Control Precautions in Food Distribution
Penalty
Summary
The facility failed to distribute and serve food in accordance with established infection control precautions. During dining observations, it was noted that kitchen personnel brought lunch trays in a food warmer cart and did not check if residents were in their rooms before taking out the trays. Specifically, trays for rooms 308-2, 309-2, and 311-1 were removed and then returned to the food warmer cart when the residents were not present. This practice was confirmed by the infection control officer, who stated that kitchen personnel must first verify if the resident is in the room before removing the tray to prevent potential contamination from room surfaces.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure the participation of all required members in the QAPI committee meetings. Specifically, the Infection Preventionist did not attend the QAPI committee meetings on multiple occasions, including May 25, 2023, September 14, 2023, October 26, 2023, February 15, 2024, and April 15, 2024. During an interview, the facility QAPI employee stated that the Infection Preventionist provided her with the infection control report and discussed relevant areas with her, which she then presented at the QAPI committee meetings. However, there was no evidence of the Infection Preventionist's direct participation in these meetings as required.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by multiple observations during a medication pass and other activities. A registered nurse did not wash her hands before putting on non-sterile gloves in four instances, picked up a piece of paper from the floor without washing her hands before continuing to serve medication, and failed to disinfect surfaces such as the medication cart and scissors used for cutting a Lidoderma patch. Additionally, the nurse placed medications on potentially contaminated surfaces, leading to potential cross-contamination risks. During an initial observational tour, dirty linen was stored near wheelchairs in a hallway, and kitchen personnel did not provide hand hygiene to residents before meals. A resident with a history of disorientation and urine incontinence was observed touching potentially contaminated areas and then eating without hand hygiene being provided by staff. Tables used by this resident were not disinfected after meals. Further deficiencies were noted during a blood glucose monitoring procedure, where a nurse left the glucometer case open, exposing its contents to the environment, and did not provide hand hygiene to the resident before giving them a breakfast tray. Additionally, clean linen was stored directly on the floor in the clean linen room due to shelving being too high for staff to reach. These observations indicate a lack of adherence to proper infection control protocols, potentially increasing the risk of communicable diseases and infections among residents and staff.
Facility Failed to Ensure Reasonable Accommodation for Residents
Penalty
Summary
The facility failed to ensure residents could reside and receive services with reasonable accommodation. During an observational tour with the Engineering Director, it was found that 3 out of 15 wheelchairs had loose brake frames, and 1 out of 2 four-contact-point walking canes had paper creating pressure on the suction cup. Additionally, 2 chairs in the occupational therapy area were found with rust. A plastic box used to store linen was observed directly on the floor of the clean linen room. The biomedical waste room was observed with the door open and garbage overflowing from the container. Furthermore, two cardboard boxes containing medical equipment (masks and lines) were observed directly on the floor of the respiratory therapy room.
Failure to Reasonably Accommodate Resident Needs During Transfer
Penalty
Summary
The facility failed to ensure residents received services with reasonable accommodation of their needs and preferences. During an observational tour, it was noted that clinical staff transferred a resident from a wheelchair to a bed using a crane in room 307. This process invaded the space of another resident in the same room, causing discomfort to the second resident. The incident highlights a lack of adequate space management and consideration for the comfort of all residents involved in the transfer process.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment as observed during a survey conducted from 05/16/2024 through 05/17/2024. Specifically, the bathroom lighting fixture did not provide adequate illumination in the shower area due to its location being lower than the shower curtain, which obstructed full light diffusion. Additionally, visual observation of residents' sleeping areas revealed an accumulation of dust particles behind the headrests of bed platforms.
Pest Control Deficiency
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests. Observations conducted from 05/16/2024 through 05/17/2024 revealed spiders, spider webs, and ants behind curtains in rooms #309, #310, #311, #317, and #319. Additionally, particulate and apparent soil indicative of an anthill starting to form was observed in the corner of room [ROOM NUMBER].
Failure to Maintain Resident Dignity During Meal Times
Penalty
Summary
The facility failed to provide services in a manner that maintained the respect and dignity of a resident. During dining observations, it was noted that a [AGE] year-old female resident with a diagnosis of a left femur fracture and periods of disorientation was seated in a wheelchair with a blue medical surgical pad placed on the seat due to her urine incontinence. The resident was observed touching her back area and the pad while eating, which compromised her dignity as it was evident to others that she had incontinence issues. The nursing supervisor confirmed that the resident had been identified with incontinence since her admission and used disposable diapers. The blue pad was used to manage large urine spills when the resident was moved outside her room or seated in the wheelchair. When asked if a fabric urine spill pad could be used to maintain the resident's dignity, the nursing supervisor acknowledged that the facility could obtain such pads. The facility's failure to use a more discreet method to manage the resident's incontinence resulted in a lack of respect and dignity for the resident during meal times.
Privacy Violation During Medical Procedure
Penalty
Summary
The facility failed to promote the right to personal privacy and confidentiality for all aspects of care and services. During observations, it was noted that a nurse (employee #7) performed a Dextrostix test on a resident in room [ROOM NUMBER]-1. Although the nurse attempted to pull the privacy curtain, it did not fully cover the resident's bed area. Despite this, the nurse proceeded with the blood glucose test. Relatives of another resident in the same room were able to see the procedure being performed, compromising the resident's privacy.
Failure to Assist Resident During Meals
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident's abilities in activities of daily living did not diminish unless clinically unavoidable. Resident #9, a [AGE] year-old female with a diagnosis of Fracture of Left Femur, was observed during a recertification survey to be eating lunch without assistance despite periods of disorientation and urine incontinence. On 05/16/2024, the resident was seen in the recreational room eating lunch from a tray without any personnel assistance. She experienced periods of distraction, during which she put down her cutlery and stopped eating, ultimately consuming only about 60% of her meal. No staff were observed supervising or cueing the resident during these distraction periods, indicating a lack of necessary supervision and assistance during meals.
Failure to Provide Necessary Care for Resident with Incontinence
Penalty
Summary
The facility failed to provide necessary care and services to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming and personal care. Resident #9, a [AGE] year-old female with a diagnosis of Fracture of Left Femur, was observed on 05/16/2024 at 10:12 AM presenting periods of disorientation and urine incontinence. Later, at 12:00 PM, the resident was seen in the recreational room seated in a wheelchair, touching her back area and pulling a blue medical surgical pad while eating lunch. Despite these actions indicating potential discomfort or incontinence, no personnel assisted the resident or checked if she needed perineal care or a change of incontinence items. This failure to review and change incontinence absorbent pads or disposable pads compromised the cleanliness of the environment where residents eat.
Failure to Meet Resident Food Preferences
Penalty
Summary
The facility failed to ensure that input received from residents and preferences related to food services were met. During dining observations, it was noted that a resident made a displeased face upon receiving her lunch tray, which contained chicken asopao as the main dish. When asked, the resident explained that while she likes soups and asopao, she does not prefer them as a main dish because they do not satisfy her hunger. The resident expressed a desire for a substitution and was informed by the surveyor that an alternate menu was available, including white rice, stewed beans, and grilled chicken. Nursing personnel were observed assisting residents with their lunch trays but did not ask if the residents were satisfied with the chicken asopao as the main dish. The nursing supervisor was informed of the resident's food preferences and the observation that nursing personnel did not inquire about the residents' satisfaction with their meals. The nursing supervisor acknowledged that it is the responsibility of the nursing personnel to ask residents if they are satisfied with their lunch items and to offer substitutions if needed.
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