Every finding on record at Centro de Cuidado Prolongado San Lucas

Based on observation and interview the facility failed to maintain all mechanical in safe and operational condition. Findings include: During kitchen observation on 03/25/2026, it was noticed that the vapor pressure gauge on serving tray steam cleaning machine was observed broken, this being broken does not assure that the proper sanitization is performed. This can affect all residents.

Based on observation and interview the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. This affected all residents.Findings include: No dietary manager was available at the moment of survey, when questioned clinical dietician stated that the dietary manager came sometimes for a couple of hours, some days. The day of the survey a kitchen employee came to work and had to leave because he was sick, this delayed breakfast serving and lunch serving, for this reason clinical dietician had to help in kitchen. This affected all residents.

Based on interview with Clinical Manager (employee # 1) and document review performed on 3/27/2026 at 10:00 AM, it was determined that the facility failed to ensure proper transmission of Payroll Based Journal-PBJ data. 1.During an interview performed on 3/27/2026, 10:00 AM with Clinical Manager (employee # 1), she stated that she submitted all quarterly reports as requested and that the system return a confirmation report with status submission as completed. She provided a document named Submission List (see attachment), which indicates that on 10/17/2025 at 11:08 AM a report was received, identified by the clinical manager as the fourth quarterly report of 2025 and on 02/09/2026 at 9:16 AM as the first quarterly report of 2026.2. During Offsite prep performed on 03/24/2026 at 11:00 AM, the regulation in iQIES platform identifies staffing concerns based on five metrics included on the CASPER PBJ Staffing Data Report, as follows:Failed to submit data for the quarter 1 2025 (October 1 - December 31)One star staffing ratingExcessively low weekend staffingNo RN hoursFailed to have licensed nursing coverage 24 hours/day3. During documents review performed on 3/27/2026 at 10:00 AM (working programs and task assignments), it was determined that every working shift was covered with registered nurses.

Based on medical records reviewed (RR) and staff interviews, it was determined that the facility failed to ensure that the baseline care plan for each resident includes the instructions, services and treatments needed to provide effective person-centered care for 2 out of 14 records reviewed (R.R #10 and #34).Findings include: 1. Resident #34 it a [AGE] year-old male admitted on [DATE] with a diagnosis of Deconditioning, Diabetes and Hypertension. During the initial pool it was observed that the resident use diaper and a Foley catheter, urine was yellow clear no sedimentation. During interview with the care giver on 03/25/2026 at 9:36 AM that on Monday 21, 2026 at 8:00 am she requests the nurse help to change the diaper due to was evacuated, the care giver stated that at 11:00 am the nurse did not arrive to help her, and she must change and provide the change of the resident diaper. Since the admission the resident used diaper and has a Foley catheter since the other hospital and was bed rest. During the record review performed on 03/26/2026 at 2:10 pm it was found that the Baseline care was developed on 03/20/2026 at 10:05 pm and did not include resident need for diaper change and the use of Foley catheter in the residents' recommendation. The initial nurse assessment performed on 03/20/2026 at 10:05 pm identified that resident has a urine catheter inserted on 03/12/2026, do not indicate the Foley number, appearance and urine color. The nurse reassessed notes. Accordance with resident classification reviewed on 03/26/2026 at 4:00 pm the resident was classification Level III, need assistance due to fecal incontinence, In the nursing assignment and duty did not include change of the diaper change. On 03/21/2026 at 16:10 pm resident physician placed an order for Foley Catheter care but did not write the Foley catheter number and the nurses note did not specify the number of the Foley catheter. On 03/24/2026 the physician placed an order to remove urinary catheter; no evidence was found in the nurse's progress note that the nurse executes the physician order. Registered Nurse #12 state on 03/26/2026 2:40 PM that Foley catheter was removed on 03/25/2026 at pm but no evidence was found in the documentation. The resident care giver state at 03/26/2026 2:41 PM that resident was urine in the diaper. 2. Resident (10) is a [AGE] year-old male admitted on [DATE] due to Decondition / Weakness. During the interview performed on 3/25/2026 at 9:00 AM, resident stated that he has weaknesses on both upper and lower extremities and needs assistance during meals. a. Clinical record shows a document named Baseline Care Plan, documented upon admission [DATE]) but it does not include information of any initial goal related to resident needs in activities of daily living, including nutrition and assistance during meals.

Based on observations of the physical environment and facility staff interviews performed on 03/25/2026 through 03/27/2026 from 8:00 AM through 5:00 PM, it was determined that the facility failed to promote the resident right to receive service in a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. This deficient practice was observed on 3 out of 8 rooms at the facility visited.Findings include: 1. During the observations performed in the residents' rooms with Institutional Program Manager (employee #2) , the following was observed: a) On 03/25/2026 at 10:01 AM it was observed in room [ROOM NUMBER]: - Broken ceiling panel.- Damp ceiling panel. - Dusty window.- Broken ceiling panel in the toilet area.- Broken light fixture cover in the toilet area.- Mold on the shower door lock and frame. b) On 03/25/2026 at 10:52 AM it was observed in room [ROOM NUMBER]:- Unsafe and loose safety grab bar is observed in the bathroom. This deficient is corrected during the survey process. c) On 03/25/2026 at 11:08 AM it was observed in room [ROOM NUMBER]:- Mold on the lamp base.- Dampness and dirt on the bathroom wall. This deficient is corrected during the survey process.

Based on records reviewed (RR) and staff interviews, it was determined that the facility failed to ensure that facility personnel develop and implement a comprehensive person-centered care plan for each resident according with resident needs for 6 out of 14 records review (R.R #1, #3, #10, #11, #33 and #34). Findings include: 1. Resident #1 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Hypertension, Diabetes Mellitus, Right Hip Infection and Lumbar Osteomyelitis. During the RR performed on 03/26/2026 3:27 PM, it was found that the pharmacist performed the Drug Regimen Review and identified the resident physician ordered on 03/02/2026 at 9:00 pm Desyrel 25 milligram (mg) by mouth (PO) at bedtime (HS), the pharmacist identified this medication as an psychotropic drug due to Mayor Depressive Disease (MDD) and monitoring mental status. However, no evidence was found that the nursing staff develop and implement a comprehensive person-centered care plan for Psychotropic Medication Use from admission until 03/26/2026. The facility nursing personnel failed to develop and implement comprehensive person-centered care plan according to residents' needs. 2. Resident #3 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Deconditioning, L4 Fracture, Diabetes Mellitus Type II, Hight Blood Pressure (HBP), Major Depressive Disease (MDD), Parkinson, Chronic Meningioma. During the RR performed on 03/26/2026 4:13 PM, it was found that the pharmacist performed the Drug Regimen Review and identified the resident physician ordered on 02/28/2026 at 9:00 am Buspar 10 mg PO daily, the pharmacist identified this medication as a psychotropic drug due to MDD and monitoring mental status. However, no evidence was found that the nursing staff develop and implement a comprehensive person-centered care plan for Psychotropic Medication Use from admission until 03/26/2026. The facility nursing personnel failed to develop and implement comprehensive person-centered care plan according to residents' needs. 3. Resident #33 is [AGE] years old female admitted on [DATE] with a diagnosis of Infection Sacral Ulcer Stage IV and Decondition. The nurse initial assessment performed on 01/02/2026 at 4:00 pm identified that resident urine spontaneous. On 03/21/2026 at 3:03 pm the physician places an order for Foley Catheter place now, the physician failed to place a complete order with Foley size and how many ways and the justification for place the catheter. No evidence was found that the nurse documented that place the catheter, the time and the Foley size, amount of urine and the urine color and appearance However, no evidence was found that the nursing staff would develop and implement a comprehensive person-centered care plan for the Foley catheter . The facility nursing personnel failed to develop and implement comprehensive person-centered care plan according to residents' needs. 4. Resident #34 it a [AGE] year-old male admitted on [DATE] with a diagnosis of Deconditioning, Diabetes Mellitus Type II and Hypertension. During the initial pool it was observed that the resident use diaper and a Foley catheter, urine was yellow clear no sedimentation. Was observed with 3 out of 4 bed rails up. During the R.R performed on 03/26/2026 1:53 PM it was found that the resident was oriented related to the Consent of authorization by the resident to raise the upper right and left rails and the lower right bed rail. The resident signs the consent on 03/20/26 at 10:05 pm. The evaluation for the use of the lateral bed was signed by the nurse, physician and the resident was performed on 02/20/2026 and provide benefit and risk for the use of bed rail. Physician identified during the initial evaluation that resident has history of Major Depressive Disorder. The physician ordered Ativan 1 mg PO HS and Seroquel 50 mg PO at HS. Since the admission the residents use diapers and have a Foley Catheter. Accordance with resident classification reviewed on 03/26/2026 at 4:00 pm the resident was classification Level III, need assistance due to fecal incontinence, In the nursing assignment and duty did not include change of the diaper. However, no evidence was found that the nursing staff develop and implement a comprehensive person-centered care plan for the physical Restraint due to the use of 3 bed rail up, Psychotropic Medication Use and fecal incontinence from admission until 03/26/2026. The facility nursing personnel failed to develop and implement comprehensive person-centered care plan according to residents' needs. 5. Resident #11 is a [AGE] year-old female resident admitted to the facility on [DATE], with diagnosis of Guillan Barre Syndrome, Decondition, Hypertension, diabetes mellitus and Sleep Apnea. During the RR performed on 03/26/2026 at 10:34 AM, it was identified that the resident has a medical order to insert a urinary catheter and provide catheter care on 03/17/2026 at 12:11 AM; which was discontinued on 03/24/2026 at 9:00 AM, however, no evidence was found that the nursing staff would develop and implement a comprehensive person-centered care plan for the Foley catheter. During the interview with the resident on 03/25/2026 at 11:50 AM, the resident was observed with a urinary catheter. She stated that after having the urinary catheter removed on 03/24/2026 in the morning, at 10:00 PM she could not urinate, so the urinary catheter was inserted again, however, no evidence was found that the nursing staff would develop and implement a comprehensive person-centered care plan for the Foley catheter. During the interview with the Director of Nursing (employee #8), on 03/26/2026 at 11:10 AM, she confirmed that the care plan related to the urinary catheter had not been activated, implement and was not in the medical record. No evidence was found that the nursing staff develops and implements the plan of care for urinary catheter in two occasions. 6. Resident (10) is a [AGE] year-old male admitted on [DATE] due to Decondition / Weakness. During the interview performed on 3/25/2026 at 9:00 AM, resident stated that he has weaknesses on both upper and lower extremities and needs assistance during meals. a. Clinical record review was performed 03/26/2026 at 11:00 AM. It shows a document named Plan de Cuidado Interdisciplinario - Estado Nutricional (Interdisciplinary Care Plan, Nutritional Status) that includes (as part of the actions plan) the assessment of the resident functional capacity to achieve food intake. It does not include measurable objectives and timeframes to meet residents' needs as identified in the comprehensive assessment nor evidence of the execution by means of the documentation of assistance during meals and final intake in each instance. b. Clinical record shows a document named Hidratación [NAME] Residente (Resident Hydration) who is documented daily. Data includes intake of the resident per hour (in milliliters), but it does not specify the kind of meal (breakfast, lunch, dinner, snack), type of food (e.g. liquids or solids) nor level of assistance per meal (Ex. Minimal, moderate or complete) needed to meet food intake.

Based on medical records reviewed (RR) and staff interviews, it was determined that the facility failed to ensure that facility personnel developed within 7 days after completion of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each assessment according with resident needs for 5 out of 14 records review (R.R #1, #3, #11, #33 and #34). Findings include: 1. Resident #1 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Hypertension, Diabetes Mellitus, Right Hip Infection and Lumbar Osteomyelitis. During the record review performed on 03/26/2026 3:27 PM, it was found that the pharmacist performed the Drug Regimen Review and identified the resident physician ordered on 03/02/2026 at 9:00 pm Desyrel 25 milligram (mg) by mouth (PO) at bedtime (HS), the pharmacist identified this medication as an psychotropic drug due to Mayor Depressive Disease (MDD) and monitoring mental status. However, no evidence that the nursing staff personnel developed within 7 days after completion of the comprehensive assessment, reviewed and update nursing care plan for Psychotropic Medication Use from admission until 03/26/2026. according to resident needs. The facility nursing personnel failed to develop and implement within 7 days after completion of the comprehensive assessment, reviewed and revised nursing care plan according to resident needs. 2. Resident #3 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Deconditioning, L4 Fracture, Diabetes Mellitus Type II, Hight Blood Pressure (HBP), Major Depressive Disease (MDD), Parkinson, Chronic Meningioma. During the record review performed on 03/26/2026 4:13 PM, it was found that the pharmacist performed the Drug Regimen Review and identified the resident physician ordered on 02/28/2026 at 9:00 am Buspar 10 mg PO daily, the pharmacist identified this medication as a psychotropic drug due to MDD and monitoring mental status. However, no evidence that the nursing staff personnel developed within 7 days after completion of the comprehensive assessment, reviewed and revised nursing care plan for Psychotropic Medication Use from admission until 03/26/2026. according to resident needs. The facility nursing personnel failed to develop and implement within 7 days after completion of the comprehensive assessment, reviewed and revised nursing care plan according to resident needs. 3. Resident #33 is [AGE] years old female admitted on [DATE] with a diagnosis of Infection Sacral Ulcer Stage IV and Decondition. The nurse initial assessment performed on 01/02/2026 at 4:00 pm identified that resident urine spontaneous. On 03/21/2026 at 3:03 pm the physician places an order for Foley Catheter place now, the physician failed to place a complete order with Foley size and how many ways and the justification for place the catheter. No evidence was found that the nurse documented that placed the catheter, the time and the Foley size, amount of urine and the urine color and appearance. No evidence that the nursing staff personnel developed, reviewed and update Foley catheter care plan according to resident needs. The facility nursing personnel failed to develop, reviewed and update nursing care plan according to resident needs. 4. Resident #34 it a [AGE] year-old male admitted on [DATE] with a diagnosis of Deconditioning, Diabetes Mellitus Type II and Hypertension. During the initial pool it was observed that the resident use diaper and a Foley catheter, urine was yellow clear no sedimentation. Was observed with 3 out of 4 bed rails up. During the record review performed on 03/26/2026 1:53 PM it was found that the resident was oriented related to the Consent of authorization by the resident to raise the upper right and left rails and the lower right bed rail. The resident signs the consent on 03/20/26 at 10:05 pm. The evaluation for the use of the lateral bed was signed by the nurse, physician and the resident was performed on 02/20/2026 and provide benefit and risk for the use of bed rail. Physician identified during the initial evaluation that resident has history of Major Depressive Disorder. The physician ordered Ativan 1 mg PO HS and Seroquel 50 mg PO at HS. Since the admission the residents use diapers and have a Foley Catheter. Accordance with resident classification reviewed on 03/26/2026 at 4:00 pm the resident was classification Level III, need assistance due to fecal incontinence, In the nursing assignment and duty did not include change of the diaper. No evidence was found that the nursing staff developed, reviewed and update nursing care plan for the physical Restraint due to the use of 3 bed rail up, Psychotropic Medication Use and fecal incontinence from admission until 03/26/2026, according to resident needs. The facility nursing personnel failed to develop, reviewed and update nursing care plan according to resident needs. The facility policy named Plan de Cuidado Integral y Centrado en el Residente- Comprehensive and Resident-Centered Care Plan was reviewed on 03/26/2026 at 11:32 AM and states that the comprehensive care plan must be completed within seven days of the resident's comprehensive assessment, or sooner if the condition requires it. This plan must include measurable goals with defined timeframes, specific interventions, assigned responsibilities, and services to maintain or achieve the resident's physical, mental, and psychosocial well-being. 5. Resident #11 is a [AGE] year-old female resident admitted to the facility on [DATE], with diagnosis of Guillan Barre Syndrome, Decondition, Hypertension, diabetes mellitus and Sleep Apnea. During the record review performed on 03/26/2026 at 10:34 AM, it was identified that the resident has a medical order to insert a urinary catheter and provide catheter care on 03/17/2026 at 12:11 AM; which was discontinued on 03/24/2026 at 9:00 AM, however, no evidence that the nursing staff personnel developed, reviewed, and update Foley catheter care plan according to resident needs. During the interview with the resident on 03/25/2026 at 11:50 AM, the resident was observed with a urinary catheter. She stated that after having the urinary catheter removed on 03/24/2026 in the morning, at 10:00 PM she could not urinate, so the urinary catheter was inserted again. However, no evidence that the nursing staff personnel developed, reviewed, and update Foley catheter care plan according to resident needs. During the interview with the Director of Nursing (employee #8), on 03/26/2026 at 11:10 AM, she confirmed that the care plan related to the urinary catheter had not been developed, reviewed, update by the nursing staff and was not in the medical record. No evidence was found that the nursing staff develops, reviewed, and update the plan of care for urinary catheter according to residents needs in two occasions.

Based on the review of the Skilled Nursing Facility (SNF) Beneficiary Notification of four (4) resident discharge, it was determined that the facility failed to ensure to inform each Medicare-eligible resident, in writing, at 48 hours previous to be discharge the Notice Medicare Non- Coverage in 1 out of 4 supplemental sample Resident (R) #38. Findings include: 1. Resident # 38 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Deconditioning, the resident was oriented related to the important messages of Medicare on 10/24/2025 at 20:13 pm, resident was discharged home on [DATE] and the Notice Medicare Non- Coverage was not provided to the resident due to the resident was a Medicare Advantage. 2. On 03/26/2026 at 8:04 am during interview with the Social Worker and discharge Planning Supervisor employee #7 state that the important messages of Medicare were provide during the admission to all residents. To resident with traditional Medicare, 2 days previously to the discharge the resident was oriented related to the Notice Medicare Non- Coverage Form CMS-10123. To the Medicare Advantage resident, they don't provide this notification form due to is the insurance plan who determined the number of days of the hospitalization. 3. The facility policy and procedure reference number: 013 title: Right to appeal to discharge in CCP reviewed on 03/26/2026 at 10:00 am refer in the item number 6, 10 and 11 that #6. For residents with a traditional Medicare plan, the social worker/discharge planner will be responsible for providing the resident with a second document titled Medicare Notification of Non-Coverage two days prior to the discharge date set by the physician. 10. For residents with a Medicare Advantage plan, the medical plan will be responsible for arranging the delivery of the Medicare Notification of Non-Coverage notice. 11. Social work staff will not be responsible for delivering this document to residents with Medicare Advantage plans because it could present conflicts of interest during an appeal, particularly if the resident requests social work representation. 7. However, no evidence was found that the Medicare Advantage plan representative oriented and provided the document to the residence. 8. The facility failed to ensure and promote the residents' right to know their rights to appeal the discharge 48 hour previous to be discharged .

Based on records reviewed (R.R), resident and staff interviews, it was determined that the facility failed to ensure that sign and date the medical orders in the medical record, related to the urinary catheter insertion for 1 out of 14 records reviewed (R.R #11).Findings include: 1.Resident #11 is a [AGE] year-old female resident admitted to the facility on [DATE], with diagnosis of Guillan Barre Syndrome, Decondition, Hypertension, diabetes mellitus and Sleep Apnea. During the interview with the resident on 03/25/2026 at 11:50 AM, the resident was observed with a urinary catheter. She stated that after having the urinary catheter removed on 03/24/2026 in the morning, at 10:00 PM she could not urinate, so the urinary catheter was inserted again. During the record review performed on 03/26/2026 at 10:34 AM, it was identified a nursing note dated on 03/24/2026 at 10:00 PM documenting that the resident reported that she had not been able to urinate after her catheter was removed in the morning. On 03/25/2026 at 12:00 AM documenting that establishes communication by phone call with patient doctor who orders the urinary catheter to be inserted again to the resident, however, the written or electronic medical order was not found in the medical record.During the interview with the Director of Nursing (employee #8), on 03/26/2026 at 11:10 AM, she confirmed that the medical order was not documented in the electronic and/or written system.

Based on records reviewed (R.R) and staff interviews, it was determined that the facility failed to ensure that a monthly drug regimen review was complete by a consultant pharmacist for 1 out of 14 records review (R.R # 2).Findings include: The facility policy named Manejo de la Revision de Regimen de Medicamentos- Medication Regimen Review was reviewed on 03/26/2026 at 2:59 PM and states that the pharmacist performs and documents the Medication Regimen Review or Drug Regimen Review process at least once a month. 1. Resident #2 is a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis of decondition, hypertension and diabetes mellitus. During the record review performed on 03/26/2026 at 1:35 PM, reveled that the drug regimen review was complete by pharmacist on the date of admission on [DATE] at 4:35 PM. However, there was no evidence in the medical record that a subsequent monthly drug regimen review was conducted within 30 days, following the initial review, as required. Further review of the record did not identify documentation of a pharmacist review for the period of February 2026. During the interview conducted on 03/26/2026 at 2:45 PM with Pharmacist (employee #10), who confirmed that did not complete a drug regimen review for the resident within the required 30 days timeframe and has pending to be carried out.

Based on interview with director of nursing (employee # 8) and record review performed on 3/27/2026 at 11:20 AM, it was determined that the facility failed to ensure reasonable efforts to review or adjust the individual resident's food plan to meet the specific needs of assistance during meals.Findings include:Resident (#10) is a [AGE] year-old male admitted on [DATE] due to Decondition / Weakness. During the interview performed on 3/25/2026 at 9:00 AM, resident stated that he has weakness on both upper and lower extremities and needs assistance during meals. Clinical record shows a document named Hidratacion [NAME] Residente (Resident Hydration) who is documented daily. Data includes intake of the resident per hour (in milliliters), but it does not specify the kind of meal (breakfast, lunch, dinner, snack), type of food (e.g. liquids or solids) nor level of assistance per meal (Ex. Minimal, moderate or complete) needed to meet food intake.

Based on review of Quality Assessment Performance Improvement- QAPI and interview with facility director of institutional program (employee #2) on 03/27/2026, it was determined that the facility failed to maintain a QAPI committee with the participation of the Medical Director or his/her designee; and Infection Control Officer in each QAPI committee meeting.Findings include:1.During review of monthly QAPI committee meeting of year 2025 and the months of January and February of year 2026 on 03/27/2026 at 11:00 AM, the following was identified:A. QAPI monthly committee meeting performed on July 18, 2025, June 20, 2025 and April 28, 2025 did not evidence the participation of the Medical Director or his/her designee.B. QAPI monthly committee meeting performed on May 20,2025 did not evidence the participation of the Infection Control Officer or his/her designee.C. Review of QAPI rules and regulation updated on August 2025 with facility director of institutional program (employee #2) on 03/27/2026 at 10:50 AM evidence that the medical director or his/her designee and Infection Control Officer must be active members required to participate in each QAPI committee meeting.D. During interview on 03/27/2026 at 11:55 AM facility director of institutional program (employee #2) stated that the Medical Director and Infection Control Officer must participate in each monthly QAPI committee meeting as established in the QAPI rules and regulation.

Based on interview with director of nursing (employee # 8) and document review performed on 3/27/2026 at 10:20 AM, it was determined that the facility failed to ensure the designation of a charge nurse in each shift to perform the specific responsibilities designated by the facility. Findings include:During an interview with the director of nursing DON (employee # 8) on 3/27/2026 at 10:20 AM, she stated that facility general supervisor acts as the charge nurse in each working shift. During a document review (staff work assignment for the three working shifts of 3/25/26 through 3/27/26) performed with the director of nursing DON (employee # 8) on 3/27/2026 at 10:20 AM, it was identified that the document does not formally designate the registered nurse as a Charge Nurse, nor specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care.

Based on review of policy and procedure with the institutional program director (employee #6), it was determined that facility failed to establish the structure to comply with resident right and exercise of right which can affect all admitted residents. This Constituted and Immediate Jeopardy to the health and safety for residents. Findings include: During the survey process it was requested to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel were assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the institutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanisms to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13-page policy were including all 483.10 resident right statement in one policy.

Based on review of policies and procedures with the Nursing Supervisor (employee #15), Acting Manager (employee # 18) was interviewed on 09/09/2024 at 9:00 AM through 9:45 AM, it was determined that the facility failed to secure itself by failing to appoint the services of a full-time Director of Nursing. The deficient practice can affect all residents admitted at the facility. This Constituted and Immediate Jeopardy to the health and safety for residents. Findings include: 1. During the interview with the Nursing Supervisor (employee # 15) at 9:30 AM, he stated that they did not have a nursing director, but they did have an acting manager. The Acting Manager (employee # 18) is also interviewed and states that there is no director of nursing. The facility failed to hire a full-time director of nursing.

Based on interview with the facility human resources personnel (employee #11), it was determined that facility failed to demonstrate is being managed in a manner that enables it to use resources effectively and efficiently. This Constituted and Immediate Jeopardy to the health and safety for residents. Findings include: 1. Credential file of the administrator was reviewed on 09/10/2024 at 11:00 AM. It was identified on this credential file that he was appointed as administrator of the hospital on June 21, 2024. This facility requests initial survey to become a Medicare provider as is a facility located in a hospital. 2. No information was found in the credential file of the administrator that indicated that he is going to be responsible for planning, organizing, and supervising the delivery of care to the residents of the facility. No information was found on this credential file that indicates that he is going to oversee and work with the facility to ensure that the facility adheres to the latest healthcare regulations pertaining to a Skilled Nursing Facility (SNF).

Based on review of governing body rules and regulations and committee meetings, it was determined that facility failed to demonstrate that had a governing body, or designated persons functioning as a governing body, legally responsible for establishing and implementing policies regarding the management and operation of the facility. This Constituted and Immediate Jeopardy to the health and safety for residents. Findings include: 1. Governing body rules and regulations and committee meetings administrator was reviewed on 09/10/2024 at 11:30 AM. It was identified on that hospital governing body had meetings on November 29, 2023, September 06, 2023, June 21, 2024, and March 06, 2024. 2. Those meetings are directed in a way that reflects that the Skilled Nursing Facility is another unit of the hospital and not a separate unit with an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility, that had specific requirements to be followed. 3. A process who evidence how the administrator is held accountable and reports specific information about the Skilled Nursing Facility (SNF) services to the hospital was not evidenced. 4. No identification of members who are going to be assigned to the SNF governing body information was provided.

Based on review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with resident right to designate a representative in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6), provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on the review of policy and procedure with the insititutional program director (employee #6), it was determined that facility failed to establish the structure to comply with the resident has the right to be informed of, and participate in his or her treatment. Findings include: During the survey process it was request to the facility the resident right manual and the personnel in charge to monitor compliance with resident rights and it was found the following: 1. No personnel was assigned to be in charge or monitor compliance of facility with resident rights. 2. The resident right facility policy and procedure reviewed on 09/10/2024 at 10:00 AM with the insititutional program director (employee #6) provide evidence that this policy was hospital based and had the logo of the policy from the Episcopal Hospital San [NAME] Metro. 3. Each of the areas of Resident right must include separate (individualized) mechanism to ensure compliance with the CMS Medicare requirement. 4. The resident right policy and procedure was a 13 page policy were include all 483.10 resident right statement in one policy.

Based on review of policies and procedures and interview with nursing supervisor (employee #15), it was determined that facility failed to promote the right of each resident to sign the forms stating they understand their condition and the proposed treatment, and that they agree to the treatment. This deficient practice was identified in 2 out of 2 closed records (CR) of residents that receive services at the facility. (CR #3 and CR #4). Findings include: 1.CR#3 reviewed is a [AGE] year-old male resident admitted on [DATE] with a diagnosis of Left Knee Replacement. Resident was admitted receiving services for short term rehabilitation after surgery. During review of the medical record on 09/09/2024 at 2:00 PM it was identified that this resident was alert and oriented when admitted to the facility, however, inform consent authorizing disclosure of information, Health Insurance Portability and Accountability Act (HIPAA) notification and treatment consent did not have the signature of the resident. 2.CR#4 reviewed is a [AGE] year-old male resident admitted on [DATE] with a diagnosis of Right Total Hip Replacement. Resident was admitted receiving services for short term rehabilitation after surgery. During review of the medical record on 09/09/2024 at 9:15 AM it was identified that this resident was alert and oriented when admitted to the facility, however, inform consent authorizing disclosure of information, and treatment inform consent did not have the signature of the resident.