Every finding on record at Hospital de la Concepcion Inc

Based on staff interview and review of staff competency practice, it was determined that the facility failed to ensure that the per diem nursing staff assigned to the skilled nursing facility completed annual competency evaluation.Findings include: On 03/05/2026 at 9:51 AM, during an interview with the Nursing Supervisor (employee #2), stated that per diem nursing is hired by the hospital. The supervisor further indicated that competency evaluations for per diem staff were conducted only at the time of initial hiring.The facility failed to ensure that all staff who provide direct care to residents must maintain current competencies that are evaluated on a periodic basis, including per diem staff.

Based on review of the responsibilities assigned to the Charge Nurse position and staff interview , on 03/04/2026 at 1:22 PM, it was determined that the facility failed to ensure that the Charge Nurse performed all the responsibilities assigned during each shift. Findings include: On 03/04/2026 at 1:22 PM, during an interview with the Nursing Supervisor (employee #2), stated that the facility assigns a Nurse leader on each shift. The nursing staff are not formally designated as nurse leaders, and the facility have not ensured that these nurses perform all the responsibilities associated with the nurse leader position. Charge Nurse is a licensed nurse with specific responsibilities designated by the facility that may include staff supervision, emergency coordinator, physician liaison, as well as direct resident care.

Based on residents interview and environmental observation on 03/04/2026, it was determined that the facility failed to ensure a comfortable room temperature for residents 3 out of 29 residents (Residents #24, #36 and #39).Findings include:According to the facility policy monitoreo Temperaturas y Humedades - Monitoring of Temperature and Humidity in the Skilled Nursing Facility- SNF, dated May 2025, Section IV states that based on ASHRAE recommendations, the temperature in resident rooms must be maintained between 70 Fahrenheit (F) and 75 F. Page 2 of 3.Resident #24 is a 64 year- old female admitted on [DATE] with Left Knee Arthroplasty. During a resident interview on 03/04/2026 at 10:45 AM, she stated that the temperature in the room was excessively cold. At the time of the observation, there was no thermometer available in the room to indicate the temperature. Proceeded to measure the room temperature using a thermometer, which registered 67.8 F, below the temperature range established by the facility's policy. Resident #36 is a [AGE] year-old female admitted on [DATE] with Right Knee Arthroplasty. During resident interview on 03/04/2026 at 11:11 AM, she stated that the temperature in the room was cold. At the time of the observation, there was no thermometer available in the room to indicate the temperature. Proceeded to measure the room temperature using a thermometer, which registered 69.7 F, below the temperature range established by the facility's policy. Resident #39 is a [AGE] year-old female admitted on [DATE] with Left Knee Arthroplasty. During resident interview on 03/04/2026 at 210:15 AM, she stated that the temperature in the room was cold. At the time of the observation, there was no thermometer available in the room to indicate the temperature. Proceeded to measure the room temperature using a thermometer, which registered 66.9 F, below the temperature range established by the facility's policy.

Base on the review of the of Skilled Nursing Facility (SNF) Beneficiary Notification of three (3) resident discharge, it was determined that the facility failed to ensure to inform each Medicare-eligible resident, in writing, at the time of admission and 48 hour previous to be discharge the Important Medicare Message in 3 out of 3 supplemental sample Resident (R) # 63, #64, and #65.Finding include: 1 . Resident #63 was a [AGE] years old female admitted on [DATE] with a diagnosis of Right (Rt) Total Knee Replacement (TKR) and was discharge to home on [DATE], during the record review performed on 03/05/2026 10:22 AM, no evidence was found related to the Important Medicare Message was provided in writing and informed at admission and at least 48 hours before discharge. 2. Resident #64 was a 78-years-old male admitted on [DATE] with a diagnosis of Rt TKR and was discharge to home on [DATE], during the record review performed on 03/05/2026 10:30 AM, no evidence was found related to the Important Medicare Message was provided in writing and informed at admission and at least 48 hours before discharge. 3. Resident #65 was a 70-years-old female admitted on [DATE] with a diagnosis of Post operated of Posterior Cervical and was discharge to home on [DATE], during the record review performed on 03/05/2026 11:40 AM, no evidence was found related to the Important Medicare Message was provided in writing and informed at admission and at least 48 hours before discharge. 4. During interview with the nurse supervisor employee # 2 on 03/05/2026 12:00 PM she states that the resident record did not have the documentation of the important message of Medicare, that she asked to the admission clerk and she notified that the important message of Medicare in the Skilled Nursing Facility (SNF) was not provided to the resident. Previously this document was provided to the resident and take the resident signature as oriented but know this documents was not provided. At this moment no resident have concern and were satisfy, and meet with their goals. 5. During interview with the admission Register Official employee #3 on 03/05/2026 at 2:00 PM, she states that since the last survey it was informed to the previous supervisor that the important Medicare Message was not provided to the resident of the SNF. The resident with primary Medicare was inform of the advance Beneficiary noted of non-coverage (ABN). 6. The important Medicare Message policy and procedure was requested on 03/05/2026 at 11:30 am, and no evidence was provided by the end of the survey , the policy was created. 7. The facility failed to ensure and promote the resident right to know their rights to appeal the discharge 48 hour previous to be discharged .

Based on medical records reviewed (RR) and staff interviews, it was determined that the facility failed to ensure that a resident's weight was monitored and documented after admission to assess the residents. This deficient practice was identified for 1 out of 29 RR (RR# 42).Findings include:During de medical record review conducted on 03/04/2026 at 11:10 AM, it was identified that the Resident Record #42 a [AGE] year-old male admitted on [DATE] with Prosthetic Joint Infection of Left Hip, had documentation of weight obtained only at the time of admission. Further review of the clinical record revealed no additional documentation of weight monitoring after admission.During an interview conducted on 03/04/2026 at 11:25 AM, Nursing Supervisor (employee # 2) stated that the facility did not have a policy regarding routine weight monitoring for residents. On 03/05/2026 at 11:10 AM, the facility provided a newly developed policy regarding weight monitoring. This policy was created after the surveyors request, confirming that such policy was not in place at the time the residents care was provided.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to Self-determination to make choices. 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 to Self-determination to make choices facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to refuse to transfer to another room in the facility 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 to refuse to transfer to another room facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to share a room with his or her spouse, share a room with his or her roommate of choice when practicable and receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed. 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 has the right to share a room with his or her spouse, share a room with his or her roommate of choice when practicable facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences. 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 to reside and receive services in the facility with reasonable accommodation of resident needs and preferences facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to be treated with respect and dignity. 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 to be treated with respect and dignity facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on the review of policy and procedure with the insititutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to choose his/her attending physician. 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 to choose his/her attending physician facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to self-administer medications if the interdisciplinary team has determined that this practice is clinically appropriate. 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 to self-administer medications facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided, the Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, contain information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulacion de la [NAME] Pública (SARP) the address and telephone was not updated.

Based on the review of policy and procedure with the institutional program director (employee #1), 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 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 to participate in the planning care facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided, the Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, contain information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulacion de la [NAME] Pública (SARP) the address and telephone was not updated.

Based on the review of policy and procedure with the institutional program director (employee #1), 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 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 and Exercise facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, containing information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulacion de la [NAME] Pública (SARP) the address and telephone was not updated.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to have provide immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems. 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 to have immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with resident right and Exercise of right. 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 and Exercise facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The Resident Rights and Responsibilities sheet provided to the resident at the admission provide evidence that this was hospital based, containing information about how to contact regulatory agency as The Joint Commission. This sheet provides to the resident the form to perform a complaint however, the Department of Health Assistant Secretary for Public Health Regulation Secretaria Auxiliar para la Regulacion de la [NAME] Pública (SARP) the address and telephone was not updated.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to inform visitation rights and equal visitation privileges. 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 visitation rights and equal visitation privileges facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that the facility failed to establish the structure to comply with the resident has the right to organize and participate in resident groups in the facility. 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 rights to organize and participate in resident groups facility policy and procedure were requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on the review of policy and procedure with the institutional program director (employee #1), it was determined that facility failed to establish the structure to comply with the resident has the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable. 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 to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided.

Based on review of policy and procedure with the institutional program director (employee #1), 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 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 Exercised by representative facility policy and procedure was requested to the facility on [DATE] at 10:00 AM and no evidence was provided, the Notice of Privacy Practices sheet provided to the resident at the admission provides evidence that this was hospital based.