Ryder Memorial Hospital Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Humacao, PR.
- Location
- 355 Ave Font Martelo, Humacao, PR 00792
- CMS Provider Number
- 405018
- Inspections on file
- 17
- Latest survey
- March 31, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Ryder Memorial Hospital Inc during CMS and state inspections, most recent first.
A resident with lumbar discitis osteomyelitis reported that when served food he did not like, staff did not offer substitute meal options, despite the dietician having assessed and communicated his preferences to the kitchen.
Surveyors found that staff did not follow proper procedures for cleaning and sanitizing kitchen equipment, including incorrect sanitizer concentration and lack of temperature knowledge. Additional issues included improper food storage, undated prepared foods, and food items left on the floor or stored with foreign materials, potentially affecting all residents.
Surveyors observed that two RNs did not consistently perform hand hygiene during medication administration, missing multiple required handwashing opportunities. Additionally, an LPN failed to change gloves during three water changes while providing a bed bath to a resident with an infected sacral ulcer.
Surveyors found that several pieces of patient care equipment, including wheelchairs, walkers, and pedal floor exercisers, had peeling paint, rust, and signs of wear, affecting all residents receiving treatment.
The facility did not ensure that advance directives were properly executed for two residents, including one with an infected sacral ulcer and another with a toe amputation. In both cases, required signatures from the resident or a representative were missing, despite staff responsibility for completing such documentation.
Multiple residents reported uncomfortably cold room temperatures, with observed readings as low as 67°F, and lacked the ability to adjust thermostats. Staff confirmed there was no system to monitor or adjust room temperatures based on resident preference. Additional issues included mold, dust, broken fixtures, and general lack of cleanliness in both resident rooms and common areas.
Surveyors identified that the facility did not consistently develop and implement baseline care plans within 48 hours of admission, with errors such as mislabeled care plans, delayed or missing signatures from clinical staff, and incomplete documentation of medical histories and consents. Two residents did not have their immediate care needs addressed promptly, and several others had incomplete or unsigned admission and care planning documents, including missing interdisciplinary team participation and blank sections in their records.
The facility did not ensure that the interdisciplinary team (IDT) fully participated in developing, implementing, and reviewing comprehensive care plans for three residents, including one with mental health needs who refused prescribed medications, another with a stage 4 sacral ulcer whose care plan lacked input from key disciplines, and a third with an incomplete MDS assessment and no involvement in their own care planning.
A resident with significant social service needs did not have those needs addressed in the comprehensive care plan, as the facility failed to include social services in the plan and did not ensure participation of the full interdisciplinary team in care plan meetings. Interdisciplinary meetings had not been held regularly, and there was a lack of documentation and follow-up by social services staff.
Surveyors found that the facility did not ensure comprehensive drug regimen reviews by a licensed pharmacist, resulting in incomplete documentation and lack of follow-up on medication refusals and new prescriptions. For example, a resident with a history of depression and anxiety refused psychiatric medications without documented oversight or education, and two other residents had incomplete pharmacy reconciliations lacking details on drug interactions or follow-up after new medications were prescribed.
A resident with deconditioning was observed leaving a scale without pants or a covering, resulting in exposure. When surveyors requested the facility's policy on procedures for female wheelchair use, no policy was provided. This reflects a failure to provide care in a manner that maintains resident dignity.
A resident with lumbar discitis osteomyelitis was not consistently provided with meals that matched his preferences, as staff did not offer substitute options when he received food he disliked, despite the dietician's assessment and recommendations being communicated to the kitchen.
The facility was found deficient in its food and nutrition service due to inadequate staffing. A Dietitian reported a lack of necessary personnel in the kitchen, and a review of the staffing pattern indicated a need for five more employees for optimal operation.
The facility failed to meet residents' preferences for breakfast timing, impacting their morning routines and therapy schedules. Three residents reported receiving breakfast after 8:30 AM, conflicting with their physical therapy sessions. The issue was linked to insufficient kitchen staff following a change in service providers, with a shortage of five employees affecting meal delivery.
The facility failed to meet the dietary preferences and nutritional needs of several residents, as observed during a survey. Residents received meals that did not align with their documented preferences, such as being served eggs and milk when they preferred black coffee and fresh fruits, or rice instead of starchy tuberous foods. The dietitian confirmed that initial assessments were conducted, but the kitchen staff did not follow the dietary specifications, affecting the quality of care.
The facility failed to provide food and drink that were palatable, attractive, and at a safe temperature, affecting several residents. Issues included meals lacking flavor and being served at incorrect temperatures, with cold items warm and hot items cold. A new kitchen service provider and staff turnover were noted as potential factors. Specific cases involved unmet dietary preferences, such as lactose-free milk and fresh fruit, highlighting non-compliance with nutritional policies.
The facility did not comply with required sink compartment sanitations. During an inspection, it was found that staff lacked knowledge of required temperatures for sink compartments, and the sanitizer concentration in the third compartment was over 600 ppm, exceeding the required 200 ppm.
The facility did not ensure the Infection Preventionist's participation in QAPI committee meetings in 2023 and 2024. The facility's rules did not require the Infection Preventionist to attend every meeting. The administrator presented the infection control findings instead.
The facility was found deficient in maintaining patient care equipment, with rust observed on 10 out of 15 wheelchairs, 1 out of 2 walking canes, and 5 out of 10 walkers in the Physical Therapy area. The parallel bars and steps also showed rust, potentially affecting all 21 residents.
The facility was found to have several environmental deficiencies, including rust in air conditioner vents, excessive dust, peeling paint, water stains on ceiling tiles, and unsecured bathroom curtain poles. These issues were observed in multiple rooms and posed potential risks to all 21 residents.
The facility was found to have a deficiency in corridor handrail security, with a loose handrail observed near a room corner. This issue had the potential to impact all 21 residents.
The facility failed to maintain an effective pest control program, leading to the presence of spiders and spider webs in the kitchen, main corridor, and residents' rooms. This deficiency had the potential to affect all 21 residents.
The facility failed to document whether three residents had advance directives during their initial evaluations, despite the residents being oriented and signing the necessary forms. This oversight was attributed to the physicians not completing the required documentation, as confirmed by RNs interviewed.
The facility was found to have several environmental deficiencies affecting resident comfort and safety. Observations revealed missing or non-functional lightbulbs in room headlights, room temperatures exceeding the facility's policy range, dusty and cobwebbed wooden closets, and inadequate water temperature in showers, leading to resident discomfort.
A resident's dietary preferences and nutritional needs were not met, as observed during a survey. Despite the resident's request for lactose-free milk and a preference for sandwiches for breakfast, these were not consistently provided. The nutritionist's recommendations were not followed, and the meals served were not in line with the resident's preferences, including the provision of canned instead of fresh fruit.
The facility failed to ensure that telephone orders taken by nursing personnel were signed and authenticated within the required 48-hour period, as per facility policy. This deficiency was identified in three cases where telephonic orders were not confirmed by the physician, despite the policy clearly stating the need for authentication within 48 hours.
The facility was found to have non-functional nurse call systems in two resident rooms, potentially affecting 4 out of 21 residents. This deficiency was identified during a survey through observations and staff interviews.
A facility failed to prioritize identifying health concerns for a resident with diabetes, who was admitted for a knee replacement. The physician ordered an insulin protocol but did not specify the insulin type, leading to nursing staff administering regular insulin without specific orders. The facility did not promptly notify the physician of this omission, delaying the correct order.
A facility failed to ensure kitchen personnel followed therapeutic diet specifications for a resident with swallowing difficulties. Despite recommendations for a blenderized diet with thickened liquids and no gelatin, the resident received a breakfast tray including gelatin. The dietitian confirmed the error, but no explanation was provided for the non-compliance with the dietary restrictions.
Failure to Provide Palatable and Preferred Food Options
Penalty
Summary
The facility failed to ensure that a resident received food and drink that was palatable, attractive, and at a safe and appetizing temperature. During dining observations and interviews, a male resident with a diagnosis of lumbar discitis osteomyelitis reported that when he was served food he did not like, staff did not offer him substitute options to ensure adequate food intake. Review of the resident's record showed that the dietician had assessed his preferences and needs, and this information was provided to the kitchen for meal preparation. However, the resident's report indicates that his preferences were not consistently accommodated during meal service.
Deficient Kitchen Sanitation and Food Storage Practices
Penalty
Summary
Surveyors observed that the facility failed to comply with required procedures for cleaning and sanitizing kitchen equipment using the three-compartment sink. Staff were found to lack knowledge of the correct temperatures for the sanitization process, and the sanitizer concentration in the third compartment was measured above the required 200 ppm, contrary to facility policy and manufacturer instructions. Additionally, the three-compartment sinks were not prepared according to the facility's established procedures. Further inspection of the kitchen and storage areas revealed several issues with food storage and labeling. Loose rice and beans were found underneath storage racks in the dry storage area, and a tuna can was left on the floor. Cut lettuce was wrapped in plastic without a date, prepared cereal (farina) was stored in a container with no preparation date, and mandarin oranges were stored in a container with apple juice wrapping and plastic inside. These deficiencies were observed to potentially affect all 24 residents receiving care at the facility.
Failure to Maintain Infection Control During Medication Pass and Bed Bath
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by direct observations during medication administration and personal care procedures. During a medication pass, two registered nurses did not consistently follow proper hand hygiene protocols. One nurse missed 1 out of 7 required handwashing opportunities, while the other missed 9 out of 11, indicating significant non-compliance with hand hygiene standards during medication administration. Additionally, a licensed practical nurse did not change gloves during three water changes while providing a bed bath to a male resident with an infected sacral ulcer, further demonstrating lapses in infection control practices. The resident involved had a medical history of an infected sacral ulcer and was receiving bed bathing care at the time of the observed deficiency. The failure to change gloves and perform hand hygiene as required were directly observed by surveyors during the care and medication administration processes.
Failure to Maintain Safe Patient Care Equipment
Penalty
Summary
The facility failed to maintain all patient care equipment in safe operating condition, as observed during an inspection of the physical therapy area. Of the seven wheelchairs inspected, three had peeling paint, visible rust, and clinical tape on the arm rests. Additionally, five out of fifteen walkers showed signs of rust and wear and tear. Both pedal floor exercisers present were also found to have signs of rust. This deficiency affected all 24 residents admitted and receiving treatment at the facility at the time of the survey.
Failure to Ensure Proper Execution of Advance Directives
Penalty
Summary
Surveyors found that the facility failed to ensure residents' rights to participate in decisions regarding their medical care and advance directives for two out of eighteen records reviewed. In one case, a male resident admitted with an infected sacral ulcer had an advance directive in his record that was not signed by either the resident or a representative. In another case, a male resident admitted with an amputation of the first toe of the right foot, who was under Family Department Service, had an advance directive that was not signed by a proxy, although the resident had marked an X on the document. Staff interviews confirmed that when residents are in the Family Services Department, staff are responsible for ensuring all paperwork is completed, but the required signatures were missing in these instances.
Failure to Maintain Safe, Comfortable, and Homelike Resident Environment
Penalty
Summary
The facility failed to ensure that residents' sleeping rooms maintained comfortable and safe temperature levels, and that the environment was clean, safe, and homelike. During a tour and interviews, several residents reported that their rooms were very cold, with observed temperatures ranging from 67 to 73 degrees Fahrenheit. Residents were seen covered with blankets and expressed a preference for warmer temperatures. It was found that certain rooms did not have accessible thermostats for residents to regulate the temperature, and the facility lacked a mechanism or procedure to monitor and adjust room temperatures based on individual resident preferences. Physical environment staff confirmed that while thermostats monitored room temperatures, the actual temperature could not be read or adjusted by residents or staff. The facility also did not have a specific policy for resident room temperatures, instead referencing a medication room temperature policy. Additional environmental deficiencies were observed, including broken bathtub curtains, detached paint, mold on walls and air conditioning grills, excessive dust on AC unit filters, rust and dust on extractor grills, and broken gypsum board. Black mold spots were noted on ceiling tiles in the physical treatment area, and excessive vegetative material was found at an emergency exit door. These conditions were observed in multiple resident rooms and common areas, affecting all residents admitted to the facility at the time of the survey.
Failure to Develop and Implement Timely Baseline Care Plans and Complete Admission Documentation
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for newly admitted residents, as identified in two out of twelve cases reviewed. In one instance, a resident admitted for rehabilitation had her care plan mislabeled with another patient's information, and the correction was made without proper evaluation or documentation. The facility was unable to provide a policy for handling such errors. Another resident with a femur fracture and urinary incontinence reported delays in receiving incontinence care, and the care plan addressing this issue was not initiated by nursing staff. Further review of additional resident records revealed multiple documentation deficiencies. These included missing or delayed signatures from physicians, nurses, and therapists on admission and care planning documents, incomplete or blank sections in medical records such as infection and vaccination histories, and lack of participation from required interdisciplinary team members in discharge planning. In several cases, essential information such as reasons for therapy consultations, notification details, and disposition of cases were absent from the records. Consent and authorization forms were also found to be incomplete or unsigned by residents or their representatives, including documents related to admission, care planning, advance directives, and vaccination consent. In one case, a resident's signature was replaced with an "X" without a supporting policy, and the facility could not provide documentation to validate this practice. These deficiencies collectively indicate a failure to ensure timely and accurate care planning, documentation, and communication at the time of admission and throughout the residents' stays.
Failure to Ensure Interdisciplinary Team Participation in Comprehensive Care Planning
Penalty
Summary
The facility failed to ensure comprehensive, person-centered care plans were developed, implemented, and reviewed with full participation from the interdisciplinary team (IDT) for several residents. For one resident with a history of anxiety disorder and depression, the care plan included medications the resident was refusing, but there was no documentation that the physician or pharmacist had been notified of these refusals. This omission occurred despite the resident's refusal of prescribed medications for mental health conditions being known at admission and during medication reconciliation. Another resident with a stage 4 sacral ulcer did not have a completed interdisciplinary care plan, as input from recreational therapy, nutrition, and pharmacy staff was missing. Additionally, there was no evidence of continuity or outcome evaluation in the care plan. Staff interviews revealed that the IDT had not officially met since the pandemic, and care plan discussions were limited to nursing staff. For a third resident with a toe amputation, the Minimum Data Set (MDS) assessment was incomplete, lacking documentation of all participants and omitting cognitive skill evaluation. The resident was also not oriented to or involved in their care plan.
Failure to Develop Comprehensive Care Plan and Ensure Interdisciplinary Team Participation
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with identified social service needs, and did not ensure participation of the full interdisciplinary team in care plan meetings. Specifically, an elderly male resident admitted with a right femur fracture and a history of disorientation was found to have significant social service needs, including lack of family support and financial resources for post-discharge care. Although the social worker initially communicated with the resident's family and referred the case to the state social services department, there was no documented social worker intervention after a certain date. The comprehensive care plan reviewed by the interdisciplinary team did not include social services areas for this resident. Additionally, the facility did not ensure that the interdisciplinary team met regularly to develop and review care plans. Staff interviews revealed that interdisciplinary meetings had not been held since the pandemic, and only partial or individual meetings occurred during MDS completion. There was no alternative method, such as virtual meetings, implemented to facilitate interdisciplinary input. The absence of regular, collaborative meetings and lack of documentation contributed to the failure to address the resident's social service needs in the care planning process.
Failure to Document and Report Medication Irregularities During Drug Regimen Review
Penalty
Summary
Surveyors identified that the facility failed to ensure a licensed pharmacist performed a comprehensive monthly drug regimen review, including proper documentation and reporting of medication irregularities as required by facility policy. For one resident with a history of anxiety disorder and depression, there was no evidence in the medical record or drug regimen review that pharmacy or physician oversight occurred when the resident refused previously ordered antidepressant and anti-anxiety medications. The reason for the refusal was not documented, nor was there any record of information provided to the resident regarding potential effects or withdrawal symptoms from discontinuing these medications. Additionally, for two other residents, medication reconciliation by pharmacy was incomplete. Although the required documentation was signed within the stipulated timeframe, it lacked details on medication reactions, interactions, and any suggestions or consultations with the medical director. In one case, a resident was prescribed opioids after the initial reconciliation, but no follow-up review was conducted. An interview with the pharmacy licensee confirmed that follow-up medication reconciliations were not performed unless specifically ordered, and documentation was limited to signatures without further detail. The facility did not have a mechanism in place to ensure ongoing monitoring of each resident's medication regimen to improve their condition or reduce risks.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to maintain the dignity of a resident during routine care. Specifically, a female resident with a diagnosis of deconditioning was observed leaving a scale without pants or a sheet covering her legs, resulting in her being exposed to view. This incident was directly observed by surveyors during the initial pool process. Additionally, when the facility was asked to provide a policy regarding procedures for female wheelchair use, no such policy was provided. These actions and omissions demonstrate a failure to treat the resident with respect and dignity, and to provide care in a manner that promotes or enhances the resident's quality of life.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
A deficiency was identified when a male resident with a diagnosis of lumbar discitis osteomyelitis reported that he was not consistently provided with food that met his preferences. During dining observations and interviews, the resident stated that when meals included items he did not like, staff did not offer substitute options to ensure adequate food intake. Review of the resident's records showed that the dietician had assessed his tastes and needs, and this information was communicated to the kitchen for meal preparation. However, the facility failed to ensure that the resident's preferences and the nutritionist's recommendations were honored, resulting in the resident not receiving meals in accordance with his stated preferences.
Insufficient Staffing in Food and Nutrition Service
Penalty
Summary
The facility was found to have a deficiency in the food and nutrition service due to insufficient staffing. During a survey conducted from May 13 to May 15, 2024, the Dietitian reported that the facility lacked the necessary personnel in the kitchen to safely and effectively carry out its functions. An examination of the kitchen personnel pattern, requested by the surveyor, revealed that five additional employees were needed for optimal operation. This deficiency was identified through both observations and an interview with the Dietitian.
Inadequate Food Service Timing for Residents
Penalty
Summary
The facility failed to ensure that residents' needs and preferences related to food services were met, as observed during a survey conducted from May 13 to May 15, 2024. Three residents reported that their breakfast was consistently delivered after 8:30 AM, which conflicted with their scheduled physical therapy sessions. This delay in breakfast delivery did not allow them sufficient time to eat calmly or attend to personal needs before therapy. The residents expressed a preference for breakfast to be served between 7:30 AM and 8:00 AM, which was not being accommodated. The deficiency was linked to a lack of sufficient personnel in the kitchen, as confirmed by the facility's dietitian. A new kitchen company had started providing services on March 1, 2024, and despite agreements to adjust food delivery to meet residents' preferences and rehabilitation schedules, the company experienced staff turnover. The kitchen manager acknowledged the need for adjustments, but the staffing pattern revealed a shortage of five employees, impacting the timely delivery of meals.
Failure to Meet Residents' Dietary Preferences and Needs
Penalty
Summary
The facility failed to ensure that the dietary preferences and nutritional needs of residents were met, as evidenced by multiple instances of non-compliance with documented dietary specifications. During the survey, it was observed that residents received meals that did not align with their stated preferences and dietary requirements. For instance, a resident who preferred black coffee and fresh fruits was served eggs, coffee with milk, and canned fruits, contrary to her dietary card specifications. Another resident, who expressed a preference for starchy tuberous foods over rice, was served rice daily, despite her dietary card indicating otherwise. Additionally, a resident who preferred sandwiches for breakfast instead of hot cereal was served scrambled eggs, which he did not like. The dietary card for this resident clearly specified his preference for sandwiches, yet this was not adhered to. Furthermore, a resident who required lactose-free milk and preferred sandwiches for breakfast was not provided with lactose-free milk, and her meals did not include fresh fruits as specified. The nutritionist's recommendations were not followed, and the meals served were not palatable or appetizing. The facility's dietitian confirmed that the initial nutritional assessments were conducted, and the residents' preferences were documented in the diet orders. However, there was no explanation provided for why the kitchen personnel failed to follow these dietary recommendations. This lack of adherence to dietary preferences and nutritional needs affected the quality of care provided to the residents, as their specific dietary requirements were not met.
Deficiency in Food Service Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was identified during a survey conducted from May 13 to May 15, 2024, affecting five residents. Residents reported that meals lacked flavor and were not served at the correct temperature, with cold items being warm and hot items being cold. The facility's dietitian acknowledged that a new kitchen company began services on March 1, 2024, and noted issues with staff turnover, which may have impacted service quality. Despite agreements with the kitchen manager to adjust food delivery to resident preferences, these issues persisted. Specific cases highlighted include a resident who did not receive lactose-free milk as per her dietary requirements and another resident who consistently received cold meals despite preferring them hot. The facility's failure to adhere to dietary recommendations and resident preferences was evident in the observations and interviews conducted. The dietitian confirmed that the milk should have been labeled as lactose-free, and the resident's preference for fresh fruit was not met, as canned fruit was provided instead. These findings indicate a lack of compliance with the facility's policy on meeting residents' nutritional needs and preferences.
Non-compliance with Sink Compartment Sanitations
Penalty
Summary
The facility failed to comply with the required sink compartment sanitations in the kitchen. During a visual inspection and staff interview, it was observed that the three-compartment sink was not prepared according to the facility's policies and procedures. The staff working at the sink lacked knowledge of the required temperatures for the different sink compartments. Additionally, when the concentration of sanitizer was measured in the third compartment, it was found to be higher than 600 ppm, whereas the requirement is 200 ppm. This overuse of the sanitizing agent could be harmful.
Infection Preventionist Absence in QAPI Meetings
Penalty
Summary
The facility failed to ensure the participation of all required members in the Quality Assessment Performance Improvement (QAPI) committee meetings. Specifically, the Infection Preventionist did not participate in the QAPI committee meetings held on several dates in 2023 and 2024. The facility's rules and procedures for the QAPI program, last reviewed in 2016, did not mandate the Infection Preventionist's participation in every meeting. During an interview, the facility administrator stated that the infection control officer provided her with the infection control report and discussed relevant areas with her, and it was the administrator who presented these findings at the QAPI committee meetings.
Deficient Equipment Maintenance in Physical Therapy Area
Penalty
Summary
The facility failed to maintain all patient care equipment in safe operating condition, as observed during a survey conducted over three days. Specifically, 10 out of 15 wheelchairs, 1 out of 2 walking canes, and 5 out of 10 walkers in the Physical Therapy area were found to have rust. Additionally, the parallel bars and steps also showed signs of rust. This deficiency had the potential to affect all 21 residents in the facility.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, staff, and the public. During an observation tour conducted with the Safety Officer, several deficiencies were noted. Rust particulate was found in the air conditioner vents in multiple rooms, including rooms #103, #104, #108, #117, and #119. Excessive dust accumulation was observed behind patients' beds and closet doors in rooms #102, #108, #112, #113, #115, #117, #119, and #120. Peeling paint was noted in rooms #108 and #119, while water and humidity stains were present on ceiling tiles in rooms #104, #107, #108, #114, #117, and #118. Additionally, bathroom curtain poles were found unsecured in 11 rooms, posing a fall risk for residents. These deficiencies had the potential to affect all 21 residents in the facility.
Deficiency in Corridor Handrail Security
Penalty
Summary
The facility failed to equip corridors with firmly secured handrails on each side, as observed during a survey conducted from 05/13/2024 to 05/15/2024. A loose handrail was specifically noted in the corridor in front of a room near the corner. This deficiency had the potential to affect all 21 residents in the facility.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests within the facility. During a kitchen tour, a live spider and spider webs were observed in the dry food storage area. Additionally, spiders were seen on the lighting fixtures in the main corridor. Further observations revealed spiders and spider webs in residents' rooms near glass windows leading to the main corridor. This deficiency had the potential to affect all 21 residents in the facility.
Failure to Document Advance Directives
Penalty
Summary
The facility failed to ensure that residents' rights to request and formulate advance directives were upheld for three out of eighteen residents reviewed. Specifically, the facility's policy required that during the initial evaluation, the physician must orient the resident regarding their right to determine their treatment and document whether an advance directive is in place. However, for Resident #105, a male with a diagnosis of Diabetes Mellitus and Right Total Knee Replacement, the record showed that while he was oriented and signed the orientation, the section indicating whether he had an advance directive was left blank. Similarly, Resident #111, a female with Deconditioning, signed the advance directive orientation, but the documentation failed to indicate if she had an advance directive. An RN interviewed stated that it was the physician's responsibility to complete this section during the initial evaluation. Additionally, Resident #124, a male with a Left Total Knee Replacement, also had a blank section regarding the presence of an advance directive despite signing the orientation. Another RN confirmed that completing this section was the physician's responsibility during the initial evaluation.
Environmental Deficiencies in Resident Rooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for its residents, as observed during a survey conducted over three days. Several deficiencies were noted, including missing or non-functional lightbulbs in room headlights in multiple rooms, which compromised adequate lighting. Room temperatures were found to be significantly higher than the facility's policy range of 68 to 72 degrees Fahrenheit, with some rooms reaching 82 to 83 degrees Fahrenheit, causing discomfort to residents who reported feeling hot and waking up sweaty. Additionally, wooden closets were observed to be dusty and covered with spider webs, indicating a lack of cleanliness. Furthermore, residents in certain rooms reported that the water temperature in showers did not reach a comfortable warm level, affecting their ability to bathe comfortably.
Failure to Accommodate Resident's Dietary Preferences
Penalty
Summary
The facility failed to ensure that a resident's dietary preferences and nutritional needs were met, as observed during a survey conducted from May 13 to May 15, 2024. The resident, a female who had undergone a right total knee replacement, expressed a preference for lactose-free milk and occasionally having a sandwich for breakfast. Despite notifying the nutritionist of these preferences, the resident continued to receive regular milk. The nutritionist's evaluation on May 7, 2024, recommended a specific diet that included lactose-free milk, no sauce food, and the option of a sandwich for breakfast, among other dietary needs. During the survey, it was observed that the resident's meal tray did not include lactose-free milk, and the lunch served was cold with no fresh fruit, contrary to the dietary recommendations. The resident expressed uncertainty about the milk being lactose-free, indicating a lack of proper labeling. An interview with a nutritionist employee confirmed that the milk should have been labeled as lactose-free. Additionally, the fruit provided was canned and not palatable, failing to meet the resident's preferences for fresh fruit. These observations highlight the facility's failure to adhere to the nutritionist's recommendations and the resident's dietary preferences.
Failure to Authenticate Telephone Orders
Penalty
Summary
The facility failed to ensure that telephone orders taken by nursing personnel were signed and authenticated in accordance with facility policies and procedures. This deficiency was identified during a review of thirteen medical records, where three cases (RR#105, #108, and #117) showed that telephone orders were not authenticated by the physician within the required 48-hour period. The facility's policy, last updated on July 15, 2016, clearly states that every order prescribed by telephone must be authenticated within 48 hours. In case #117, nursing personnel received telephonic orders on two occasions, but no authentication or confirmation by the physician was evidenced within the required timeframe. Similarly, in case #105, telephonic orders were received on two separate occasions, yet no authentication was documented. In case #108, telephonic orders were also received twice, with no subsequent authentication by the physician. The nursing supervisor confirmed that the facility's policy mandates authentication within 48 hours, which was not adhered to in these instances.
Non-Functional Nurse Call Systems in Resident Rooms
Penalty
Summary
The facility failed to maintain adequately equipped rooms to allow residents to call for staff assistance. During observations of the physical environment and interviews with facility staff conducted over a three-day period, it was found that the nurse call systems in rooms #102 and #106 were not functioning. This deficiency had the potential to affect 4 out of 21 residents in the facility.
Failure to Specify Insulin Type in Protocol
Penalty
Summary
The facility failed to ensure that treatment and care provided to residents prioritized identifying health concerns, as evidenced by the case of a female resident who was admitted with a diagnosis of left knee replacement. The resident, who also had a history of diabetes, was supposed to have her blood sugar levels monitored every six hours, with regular insulin administered if levels were out of the expected range. However, a review of her medical record revealed that while a physician ordered a subcutaneous insulin protocol, they did not specify the type of insulin to be administered when blood sugar levels were abnormal. The nursing supervisor confirmed that the physician did not select the type of insulin in the protocol, leading to nursing personnel administering regular human insulin on two occasions without specific orders. The facility did not notify the physician immediately upon identifying the omission in the insulin protocol, resulting in a delay in obtaining the correct order. This oversight highlights a failure to ensure timely consultation with the physician when necessary aspects of resident treatment were identified.
Failure to Follow Therapeutic Diet Specifications
Penalty
Summary
The facility failed to ensure that kitchen personnel followed therapeutic diet specifications consistent with a resident's comprehensive assessment. This deficiency was identified during a survey conducted from May 13 to May 15, 2024, affecting one out of thirteen records reviewed. The resident involved was a male with a diagnosis of a left femur fracture, who was experiencing difficulty swallowing food. A Speech Language Pathologist (SLP) evaluated the resident and recommended a diet of blenderized food with thickened liquids to reach a puree consistency, explicitly advising against broths and gelatin. Despite these recommendations, on May 15, 2024, the resident was observed receiving a breakfast tray that included gelatin, which was against the specified dietary restrictions. The facility dietitian confirmed that the resident received gelatin and acknowledged that kitchen personnel must comply with diet recommendations. A review of the kitchen card with diet specifications for the resident clearly indicated that no gelatin should be served. However, no explanation was provided by the dietitian as to why the kitchen personnel did not adhere to the correct diet recommendations, resulting in the facility's failure to offer a therapeutic diet as ordered by the healthcare provider.
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