Ponce Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Ponce Health and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF645May 15, 2025

  Based on observations, interviews and record review the facility failed to ensure residents received an accurate Preadmission Screening and Resident Review (PASRR) Level I screening and a Level II screening for one (Resident 91) out of two residents reviewed. Resident 91 did not receive a PASSAR Level II after admission to the facility. There were a total of 139 residents residing in the facility at the time of this survey. The findings included: Record review of the Preadmission Screening and Resident Review (PASSR) Policy and Procedure (reviewed January 2025) documented: Policy-The facility ensures that a all residents admitted to the facility has PASSR Level I done prior to admission to facility or Level II as indicated by resident's condition and diagnosis of resident. […]

• No harm, potential for more than minimal, isolatedF867May 15, 2025

  Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct an identified quality deficiency in the problem area related to repeated deficient practice for F645- PASARR Screening for Mental Disease (MD) and Intellectual Disability (ID). As evidenced by: F645 was cited during a Recertification survey ending 12/21/23 when the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASRR) was completed accurately prior to admission and failed to revise the screening following admission for four (4) Residents This repeated deficient practice has the potential to affect any of the 139 residents residing in the facility at the time of the survey. […]

• No harm, potential for more than minimal, isolatedF880May 15, 2025

  Based on observation, record review and interviews, the facility failed to follow infection prevention and control procedures for Residents ( #13, #106, #129, #234). As evidenced by Residents # #13, # 106, #129, and #234 Incentive Spirometer were observed stored at bedside with no protective covering. There were 139 residents residing in the facility at the time of the survey. The findings included: Resident #13 During an observation on 05/12/25 at 06:51 AM Resident #13 was in bed asleep, an Incentive Spirometer was on the bedside table with no protective covering (Photo Evidence) On 05/13/25 at 08:21 AM Resident # 13 was observed in bed awake, eating breakfast, an Incentive Spirometer was being stored on bedside table with no protective covering. […]

• No harm, potential for more than minimal, isolatedF645Dec 21, 2023

  Based on record review and interview, the facility failed to ensure a level 1 Preadmission Screening and Resident Review (PASARR) was completed accurately prior to admission and failed to revise the screening following admission for four (4) Residents (#13, #48, #49, #81) out of 28 sampled residents. There were 135 residents residing in the facility at the time of the survey. The findings Included: 1. During observation on [DATE] at 09:27 AM Resident #13 was in bed, complained of call light not working properly that was resolved by the Maintenance Director immediately. […]

• No harm, potential for more than minimal, isolatedF689Dec 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure the safety of vulnerable residents for one out of two sampled residents (Resident #88) for smoking. As evidenced, Resident #88 was smoking out in the smoking area with no staff supervision. This deficient practice has the tendency to affect all 7 residents who smoke at the facility at the time of the survey. The findings included: On 12/19/2023 at 11:14 AM, during an interview with Staff B, a Certified Nurse Assistant, she stated that she was the one who watches the residents when they go to smoke. […]