Every finding on record at Multy Medical Skilled Nursing Facility

Based on review of Quality Assessment Performance Improvement- QAPI and interview with facility compliance officer (employee #2 ) on 03/26/2026, it was determined that the facility failed to maintain a QAPI committee with the participation of administrator, owner, a board member or other individual in a leadership role; in each committee meeting.Findings include:1.Review of quarterly QAPI committee meeting 2025 and 2026 on 03/26/2026 at 10:20 AM, the following was identified:A. QAPI committee meeting performed on January 14, 2026 did not evidence the participation of administrator, owner, a board member or other individual in a leadership role.B. QAPI committee meeting of the first quarterly of year 2025. January, February and March 2025 attendance list did not demonstrate participation of administrator owner, a board member or other individual in a leadership role.C. Review of QAPI rules and regulation updated on 01/08/2026 with QAPI compliance officer (employee# 2) on 03/26/2026 at 11:35 AM did not include in the section of governance and leadership that the Administrator or leadership personnel must be part of the required QAPI committee members. D. During interview on 03/26/2026 at 11:35 AM QAPI compliance officer (employee# 2) stated that administrator, owner, a board member or other individual in a leadership role; did not participate in each committee meeting.

Based on observations, review of logs, policies and procedures and interview, it was determined that the facility failed to ensure that the medication room conserves adequate temperature levels and relative humidity. This deficiency affects 17 out of 17 residents in the facility.Findings include:The facility policy named Control de Temperatura y Humedad - Cuarto de Medicamentos Temperature Control and Humidity- Medication Room was reviewed on 03/26/2026 at 11:31AM and states The room temperature must be maintained between 72 and 78 degrees Fahrenheit ( F), and the relative humidity between 20% and 60%. If either of these readings is outside the specified range at the time of measurement, this must be reported, and the corrective actions taken must be documented. The medication room was visited on 03/26/2026 at 8:44AM and it was noted that the temperature was 71.9 F and the relative humidity was 72%.The temperature and relative humidity logs from December 2025 through March 2026 were reviewed on 03/26/2026 at 1:27PM and the following was noted:On January 2026 the temperature was over 78 F 7 out of the 31 days, and the relative humidity was over 60% 7 out of the 31 days.On February 2026 the temperature was over 78 F 2 out of the 28 days, and the relative humidity was over 60% 3 out of the 28 days.On March 2026 the relative humidity was over 60% 21 out of the 26 days. On an interview with the director of nursing (employee #1) on 03/26/2026 at 1:30PM she states that no correctives actions were taken or documented.

Based on staff interview, it was determined that the facility failed to ensure the submission if Payroll-Based Journal (PBJ) data to CMS.Findings include:On 03/25/2026 at 2:20 PM, an interview was conducted with the Director of Nursing (DON) (employee #1) to determine who was responsible for completing and submitting the Payroll-Based Journal (PBJ). The DON stated that she was not responsible for this task.1.At 2:42 PM, an interview was conducted with the Director of Compliance, who reported that PBJ reporting had been the responsibility of the administrator's resignation, PBJ data had not been submitted and the facility had recently become aware that no one had been assigned to continue this responsibility.2.This finding indicates the facility failed to ensure ongoing compliance with federal requirements for PBJ data submission.

Based on review of Quality Assessment Performance Improvement- QAPI and interview with facility compliance officer (employee #2 ) on 03/26/2026, it was determined that the facility failed to consider residents feedback as quantifiable data to enhance care and ensure safety. Findings include:1.Review of QAPI activities of year 2025 and first quarter of year 2026 on 03/26/2026 at 10:30 AM, the following was identified:A. Administration clerk officer ( employee #6 ) present on 03/26/2026 at 9:50 AM information collected during year 2025 related with resident satisfaction surveys.B. Accordingly with information provided by facility compliance officer (employee #2 ) on 03/26/2026 at 11:55 AM facility collect on an ongoing basis resident experience while receiving services at the facility in a satisfaction survey questionnaire. He explain that this information is not discussed as part of QAPI committee meeting and activities.C. Facility failed to align healthcare services provided considering resident needs and expectations in order to identify areas where they can improve their services.

Based on observation and interview, the facility failed to maintain the physical environment in a safe and functional manner to ensure resident safety. Specifically, handrails were not maintained in good repair.Findings Include:During a tour of the facility on 03/26/2026, observation of handrails located in corridors revealed the following:Handrails with loose corner sectionsHandrails with uneven surfaces, creating irregular gripping areasThese conditions were observed in the following locations: Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room [ROOM NUMBER]Next to room men visitors bathroomInterview with the engineer (employee #3) confirmed that the handrails were not in good repair and no immediate corrective action had been taken at the time of survey. Handrails that are loose or have uneven surfaces may not provide adequate support for residents, increasing the risk of slips, trips, and falls.

Based on the observations and interviews conducted, it was determined that the facility failed to provide a safe environment, specifically regarding the bathrooms in the residents' rooms. This deficiency was observed in 5 of the 16 residents interviewed.Findings include: During the initial pool interviews 5 residents were interviewed (75, 76, 77, 78 and 79) and the 5 residents stated that the water came out of the bathroom when they were showering. Also, they state that the nursing staff instructed all the resident to put the bed sheets on the bathroom floor when they are going to take a shower, so the water does not go out of the bathroom.The resident #76 was visited on 03/25/2026 at 9:15AM and it was noted that she just came out of the shower and there was water under the bed that came from the bathroom when she was showering. A nurse came in the room and asked the resident if she put the bed sheets on the floor before showering but the resident didn't.The resident #76 was visited on 03/25/2026 at 8:10AM and it was noted that she was getting out of the shower again. This time the resident did put the bed sheet on the bathroom floor, but the water was out of the bathroom either way.

Based on resident interview, record review, and staff report, it was determined that the facility failed to ensure a safe, comfortable, and adequately accessible bathroom environment for 1 out of 1 sampled resident (resident #88). Findings include: Resident #88 is a 59-years-old female admitted on [DATE] with a diagnosis of Left Total Knee Replacement (TKR). During an interview conducted on 03/25/2026 at 9:42 am, the resident reported that the bathroom space was very uncomfortable and difficult to use. She stated that during a recent bathroom use with assistance from nursing staff, she became entangled between her walker and the commode, causing her to slide to the floor. The resident further stated that nursing staff attempted to assist her in maintaining a standing position but were unable to prevent the fall. The resident expressed that the bathroom should be more comfortable and accessible for safe use. Review of facility documentation revealed that on 03/22/2026 at 11:30 AM, an incident/accident report was completed regarding the event. Documentation confirmed that the resident was evaluated by a physician following the incident.

Based on staff interview, it was determined that the family failed to maintain posted daily nurse staffing information for the required retention period of at least 18 months. Findings include:On 03/25/2026 at 3:15 PM, requested the facility's posted daily nurse staffing information for the previous 18 months. The facility was only able to provide documentation from 10/01/2025 to the present.During an interview conducted on 03/25/2026, the Director of Information Technology (employee #4) stated that attempts were made to retrieve prior staffing postings; however, these efforts were unsuccessful.This finding indicates the facility failed to retain posted nurse staffing information in accordance with federal requirements.

Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to comply with the resident right promote and facilitate resident self-determination through support of resident choice. 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. The resident right to promote and facilitate resident self-determination through support of resident choice facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.

Based on review of policy and procedure with the facility Administrator (employee #3), 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 rights and Exercise facility policy and procedure Manual was requested to the facility on [DATE] at 10:00 AM and no evidence was provided. The facility provides different policy and procedure related to resident right that was in English language only as: a. Policy #4000 Resident Care policies that were in the administrative Manual. b. Policy #4005 Resident Right policies, 2 pages that were in the administrative Manual. c. Policy #4010 Access Visiting policies 3 pages that was in the administrative Manual, that covers the different tags F563, F564 and F565. d. Policy #4015, 4015.1, 4015.3, 4015.4 Elder / Dependent Adult Abuse policies 9 pages that was in the administrative Manual and was and interpretation of the State Operation Manual.483.12 (b, c) and 483.75 and do not have purpose and policy. e. Policy #4025 Facility Rules and Information that was not a policies 90 pages that was in the administrative Manual, that cover the different tag F551, F555, F557, F567, F568, F569, 570, 571, F576, F578, F585, F604, F605 F606 and F621, F625 and do not have update hot line number. f. Policy #4030 Informed Consent- Psychotherapeutic Medications and Restraint Device policies 10 pages that were in the administrative Manual and was and interpretation of the State Operation Manual 483.10 (c, e). g. Policy #4032 Civil Rights Review policies 2 pages that was in the administrative Manual. h. Policy #4040 Restraint-Physical Policies 10 pages that was in the administrative Manual and was and interpretation of the State Operation Manual.483.12 (a). i. Policy #4041 Restraint-Psychotropics Drug policies 4 pages that was in the administrative Manual and was and interpretation of the State Operation Manual.483.12 (a) and 483.45 (e) (1). j. 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 (SARSP) the address and telephone was not updated.

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that the facility failed to establish the structure to comply with the resident right to receive visitors of his or her choosing at the time of his or her choosing Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident has the right to receive visitors of his or her choosing at the time of his or her choosing, policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident's right to receive visitors of his or her choosing at the time of his or her choosing policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.

Based on the review of policy and procedure with the facility Administrator (employee #3), 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.

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents' 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 it was found the following: 1. The resident right to self-administer medications facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.

Based on the review of policy and procedure with the facility Administrator (employee #3), 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 it was found the following: 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 10:15 AM and no evidence was provided.

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the residents' 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 10:15 AM and no evidence was provided.

Based on review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident rights 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. The resident right to refuse to transfer to another room facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to 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's rights manual, and it was found the following: 1. The residents right to immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems policies and procedures were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to immediate access to any representative of the State, to resident's individual physician, to any representative of the protection and advocacy systems policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident 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 it was found the following: 1. The resident right to organize and participate in resident groups in the facility policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident right to organize and participate in resident groups in the facility policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident has the right to choose or refuse to perform services for the facility. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to choose or refuse to perform services for the facility policy and procedure was requested to the facility on [DATE] at 10:15 AM and no evidence was provided.

Based on the review of policy and procedure with the facility Administrator (employee #3), it was determined that facility failed to establish the structure to comply with the resident right to be informed of his or her visitation rights and equal visitation privileges. Findings include: During the survey process it was requested to the facility the resident right manual, and it was found the following: 1. The resident right to be informed of his or her visitation rights and equal visitation privileges policies and procedure were requested to the facility Administrator (employee #3). As part of the Resident Right structure facility present on 09/25/2024 at 11:55 AM policies and procedures written in English. Those policies and procedures did not include the concise description of the rules that the facility must follow to comply with resident right to be provided to residents. The policies and procedures do not include the date when each policy was created or the approval of the governing body. 2. The resident's right to be informed of his or her visitation rights and equal visitation privileges policies and procedures did not include key elements in the policy to ensure clarity and effectiveness like policy purpose and scope, responsibilities and roles of department involved in implementing and enforcing the policy.