Every finding on record at Servicios Integrados de Rehabilitacion (Siro) Inc

Based on observations made on 3/10/2026 through 3/11/2026 from 8:00 AM to 4:00 PM, it was identified that the facility failed to assure that all mechanical, electrical and patient care equipment is maintained in safe operating condition. Findings include:Facility policy named: Protocolo uso de equipo electrico en cuarto de los residentes (March 2024 revision) Protocol Use of Electrical Equipment in Residents Rooms, was reviewed on 3/11/2026 at 11:15 AM. The policy states that every equipment brought by the patient will be inspected by the physical plant personnel, after which a seal will be placed on it. Observations during a round performed on 3/10/2026 at 11:00 AM include:Resident # 25 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. room [ROOM NUMBER]-A. During the resident interview and observation performed on 3/10/26 at 11:00 AM, it was identified an apnea machine at the head of the bed. Resident stated that she has a diagnosis of sleep apnea. Upon admission she brought her own machine to the facility, which was inspected by the staff. An observation of the equipment was performed by the surveyor on 3/11/2026 at 11:20AM. There is no seal indicating the inspection done, as per facility policy.

Based on observation and staff interview, it was determined that the facility failed that the medication carts were properly secured to prevent unauthorized access to medication.Findings include:During a tour of the medication storage area on 03/10/2026 at 9:05 AM, accompanied by a Registered Nurse (employee #6), it was observed that the medication cart drawers assigned to room # 107 B, 108 A, 108 B, and 109 could be opened even through the medication cart was in the locked position.During a staff interview om 03/10/2026, the Charge Nurse (employee #3) indicated that a defective equipment report had been completed regarding the medication cart. The Charge Nurse further indicated that a representative from Unicare visited the facility and provided a quotation for repair services.Following the observation, the medications from drawers #107 B, 108 A, 108 B, and 109 were relocated to other secured compartments of the medication cart where the drawers could not be opened and the medications remained under staff custody.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that the medication reconciliation included the pharmacist's review and signature in the resident's clinical record 2 out 8 (Resident #33, #35).Findings include:1.Resident #33 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During a review of the clinical reord conducted on 03/11/2026 at 11:29 AM, it was observed that the medication reconciliation form in the resident's medical record lacked documentation of the phatmacist's review and signature.2. Resident #35 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During a review of the clinical reord conducted on 03/11/2026 at 10:48 AM, it was observed that the medication reconciliation form in the resident's medical record lacked documentation of the phatmacist's review and signature.

Based on medical record review and staff interview, it was determined that the facility failed to ensure that the pharmacist reviewed and documented the resident's medication regimen in the clinical records. This deficient practice was identified in 3 out of 8 (Residents # 25, #33, #35).Findings include: Review of the facility policy Revisión de Medicamentos Innecesarios, Intervención de Farmacéutica Procedure: Indicated that the pharmacist is responsible for conducting a medication regimen review upon a resident's admission to the facility. The policy indicated that the pharmacist utilizes the medication reconciliation, physician orders, and the medication administration record (MAR) to perform this review. The policy further indicated that the pharmacist will complete this review within approximately 72 hours [NAME] the resident is admitted to the facility, Page 1 of 3. 1.Resident #33 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the review of the clinical record conducted on 03/11/2026 at 11:29 AM, it was observed that the medical record did not contain documentation of the pharmacist's medication regimen review as required by the facility's policy. 2. Resident #35 is a [AGE] year-old male admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the review of the clinical record conducted on 03/11/2026 at 10:48 AM, it was observed that the medical record did not contain documentation of the pharmacist's medication regimen review as required by the facility's policy. 3. Resident # 25 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 3/11/26 at 11:30 AM, it was identified that the medical record did not contain documentation of the medication regimen review (MRR) as per facility policy. 4. Resident Sample #26 is a [AGE] year-old female admitted on [DATE] with diagnosis of Right Total Hip Replacement. During the record review performed 03/11/2026 at 11:00 AM provide evidence of physician admission orders of Keflex 500 mgs 1 tablet PO q 6 hours x 4 doses and Tylenol with Codeine 1-2 tablets q 4 hours for pain on 03/04/26. Medication regimen review performed by pharmacist for this case who had opioids and antibiotics was not found documented on the medical record.

Based on interview with MDS Coordinator (employee # 3) and document review performed on 3/11/2026 at 11:00 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 MDS Coordinator (employee # 3) on 3/11/2026 at 11:00 AM, She stated that the registered nurse assigned to each shift is also the charge nurse. During a document review (staff work assignment for the three working shifts of 3/10/26 and 3/11/26) performed with the MDS Coordinator (employee # 3) on 3/11/2026 at 11:00 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 observation conducted at front of the nursing station on 03/10/2026, it was determined that the facility did not ensure that the following information was posted and readily accessible to residents, and family members and legal representatives of residents.Findings include:1. During arrival at the facility on 03/10/2026 at 8:20 AM, the following was observed:a. The results of the most recent survey of the facility posted on a bulletin board in front of nurse station were dated 04/23/2024, 04/05/2023 and 05/05/2023.b. This facility's last recertification survey conducted was on 04/29/2025.c. On 03/11/2026 at 3:14 PM, MDS coordinator (employee #3) and Chief Executive Officer (employee #4), were interview they stated that an updated report with respect to the most recent recertification surveys, any certifications, and or complaint investigations at the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, must be available for any individual to review. 2. However, the reason why the last Medicare recertification survey conducted on 04/29/2025 and plan of correction was not included nor was provided.

Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/28/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice had the potential to affect 18 out of 18 residents receiving services at areas where the deficient environment and items. Findings include: 1. Water damage and humidity noticed on bathroom ceiling and A bed area of room [ROOM NUMBER]. 2. Water drops caused by condensation on air conditioning vents were observed wetting the floor in front of exit door to back patio, this is a slip and fall risk.

Based on an interview with the Infection Control coordinator (employee #1) on 4/29/2025, it was determined that the facility failed to ensure an antibiotic stewardship program that promoted appropriate antibiotic use and included education of nursing and medical staff. Findings include: 1. During the review and interview of the Infection Control Program's Stewardship antibiotic program, the following were identified: a. Prolonged use of antibiotics in residents without documented justification in a report sent to the Puerto Rico Department of Health on a monthly basis. The report demonstrates the monthly volume of patients using antibiotics but is not specific. b. Policies and procedures that include written stewardship material were reviewed: dosage, indication, renal adjustment, administration, precaution, monitoring, and dilution and stability of the antibiotic. Despite having them available, they do not maintain an educational program on the appropriate use of antibiotics for physicians and nursing professionals, thus impeding the appropriate use of antibiotics and their justification in residents. On 4/29/25 3:30 PM during the interview with the Infection Control Program Coordinator (Employee # 1) revealed that they have no education on the appropriate use of antibiotics of Stewardship for physicians and nursing professionals.

Based on observations, staff interviews and review of policies and procedures on 04/28/2025 through 04/29/2025 at 8:12 AM through 3:30 PM, it was determined that the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings incliude: 1. During the round conducted in the residents' rooms, the following was observed: a. On 04/28/2025 at 9:48 AM, the physical therapy assistant (employee #4) was observed entering room [ROOM NUMBER] A without washing her hands and without wearing gloves while placing ice packs on Resident #201. The Director of Nursing (DON) (employee #1) was interviewed on 04/29/2025 at 10:45 AM, and asked for a policy and procedure for the placement of cold compresses. When the DON provided the policy, the lack of integration of hand washing and glove use into the procedure was noted. 20423 2. During the medication Pass performed on 4/29/2025 from 8:10 AM till 8:50 AM it was observed the following: a. During the medication pass with the registered nurse employee #3, it was observed that the failed to wash her hand on 4 out of 10 opportunity to wash her hands before open the door of 5 resident rooms.

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/28/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: During observational tour of kitchen on April 28, 2025, approximately from 8:27 AM through 12:00 PM the following was identified: 1. Chicken pieces were observed in the freezer. They were found in a broken, sealed package with exposed parts outside the wrapping and covered in plastic wrap. Kitchen staff indicated that they had been received from the supplier in that condition. 2. Kitchen staff were observed using a scoop to serve rice. Staff cleaned the utensil without the proper process of letting it air dry after sanitizing. 3. The kitchen supervisor was observed near the food serving area without wearing a hairnet.

Based on an interview with the Minimum Data Set- (MDS) coordinator (employee #2), it was determined that the facility failed to accurately electronically transmit resident assessment instrument status correctly in 2 out of 2 closed records reviewed (RR). (Resident #1 and #2) Findings include: 1. During the records reviewed the electronic system identified resident #1 as a hospitalization . On 04/29/24 at 10:00 AM during the record review it was found that Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Left Total Knee Replacement, in the record appears that resident #1 receive her treatment and on 03/14/2025 the resident have an appointment with the Orthopedic physician and do not want to return to the facility to completed her treatment per one day due to the physician planned to discharge on 03/15/2025. She requests to the facility exonerate one day on 03/14/2025 of rehabilitation, and resident was discharged to home on 03/14/2025, with a discharge summary with Home Care, and medical equipment. The MDS Section A A0310 F, she marks 10 discharge assessment- return not administrate. The MDS was completed on 03/14/2025. During the interview on 04/29/205 at 10:15 AM with the MDS Coordinator Employee #2, stated, this resident was discharged to the community, however when the information was entered to the system on 03/18/2025 was documented by error short-term general hospital. On 04/29/2025 at 10:25 AM, she corrects this error as Discharge and was transmitted correctly and accepted. 51829 2. During the records reviewed the electronic system identified resident #2 as a Unplanned (facility Initiated) Discharge. On 4/29/25 10:30 AM during the record review it was found that Resident #2 was a [AGE] year-old male, admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement (Rt TKR). The record revealed that the social work planned the discharge from the moment of admission. Discharge notification was not made because the resident presented changes in health, therefore, he was transferred to the hospital on 01/23/2025 due to an rule out (R/O) of kidney failure. The MDS coordinator employee #2 interviewed on 04/29/2025 at 10:43 AM refer that this resident was hospitalized , however when the information was entered to the system was document by error discharge Home. On 4/29/2025 at 9:41 AM she corrects this error and was transmitted correctly and accepted.

3. Resident #205 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 04/29/25 at 2:00 PM, it was found that has physician ordered on 04/25/2025 at 8:10 PM Cymbalta 30 mg 1 tab PO Hour Sleep (HS). No evidence was found related of the justification for the use of this antidepressant in the physician progress notes. During the interview with the Director of Nursing (employee #1) on 04/29/2025 at 2:00 PM she stated that residents arrive with instructions and a prescription from their orthopedic surgeon to continue treatment at the facility. She states that the orthopedic surgeon prescribed Cymbalta for pain management, not as an antidepressant. The physician at the time of admission fills the order based on the orthopedist's prescription order. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication. 2. Resident #201 is a [AGE] year-old female admitted on [DATE] with Right Total Knee Replacement. a. During the medical record review on 04/29/2025 at 2:35 PM, it was noted in the medical order made on 04/26/2025 at 8:00 PM, Trazodone 100 miligrans (mg) 1 tablet oral at bedtime. On 04/29/2025 at 3:03 PM, the medical history was reviewed and no history of depression was found in the pre-admission screening sheet. The medical record was reviewed on 04/29/2025 at 3:15 PM, no physician's progress note was found that could justify the use of antidepressant for the resident. The Director of Nursing (DON) (employee #1) was interviewed on 04/29/2025 at 2:45 PM, stated that when the resident is admitted he/she arrives with a prescription order. The physician at the time of admission fills the order based on the orthopedist's prescription order. Based on reviews of 8 medical records and interviews conducted on 04/28/2025 to 04/29/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure that the residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice affects 3 out of 8 receiving services at the facility (RS #102,# 201 and #205). Findings include: 1. Resident 102 is a [AGE] year-old female admitted to the facility on [DATE], with a diagnosis of Right Total Knee Replacement. During the record review, performed on 04/29/2025, at 12:00 P.M., it was found that has a physician order on 04/24/2025, for medication Cymbalta 30 mg orally at bedtime. On the high-risk medication review sheet, the pharmacist documented that this was an antidepressant. No justification for the use of this antidepressant was observed in the physician notes. a) During the interview with the Director of Nursing (employee #1), she stated that the residents arrived with instructions and a prescription from their orthopedic surgeon to continue treatment at her facility. She states that the orthopedic surgeon prescribed Cymbalta for pain management, not as an antidepressant. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication.

Based on reviews of 8 medical records and interviews conducted on 04/28/2025 to 04/29/2025 from 8:00 AM to 4:00 PM, it was determined that the facility failed to ensure that each resident's medication regimen is free of unnecessary medications. This deficient practice affects 3 out of 8 receiving services at the facility (RS# 102, # 201 and 204). Findings include: During the investigations carried out in the clinical records concerning antibiotic treatment, the following was observed: 1. Resident #201 is a [AGE] year-old female admitted on [DATE] with Right Total Knee Replacement. a. During the medical record review on 04/29/2025 at 2:35 PM, it was noted in the medical order made on 04/26/2025 at 8:00 PM, Augmentin 875 mg 1 oral tablet twice a day for 20 doses. On 04/29/2025 at 3:03 PM, the clinical record was reviewed the admission care plan in the skin status the nursing staff only wrote that the knee area was noted with surgical patch and edema. The medical record was reviewed on 04/29/2025 at 3:15 PM, no physician's progress note was found that could justify prolonging the resident's antibiotic treatment. 51782 2. Resident #102 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 04/29/25 at 12:00 PM, it was found that has physician order on 04/24/2025 for the antibiotic Cipro 750mg orally every 12 hours for 20 doses. No justification for the use of this antibiotic was observed in the physician notes. a) During the interview with the Director of Nursing (employee #1) she stated that residents arrive with instructions and a prescription from their orthopedic surgeon to continue treatment at her facility. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication. 20423 3. Resident #204 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 04/29/25 at 1:00 PM, it was found that has physician ordered on 04/27/2025 at 1:15 PM the antibiotic Augmentin 875 milligram (mg) 1 tablet (tab) per mouth (PO) twice daily (BID) per 20 doses. No evidence was found for the justification for the use of this antibiotic in the physician progress notes. During the interview with the Director of Nursing (employee #1) on 04/29/2025 at 1:30 PM she stated that residents arrive with instructions and a prescription from their orthopedic surgeon to continue treatment at the facility. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication. 4. Resident #205 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Right Total Knee Replacement. During the record review performed on 04/29/25 at 2:00 PM, it was found that has physician ordered on 04/25/2025 at 8:10 PM the antibiotic Keflex 500 mg 1 tab PO three time daily (TID) per 10 doses. No evidence was found related of the justification for the use of this antibiotic in the physician progress notes. During the interview with the Director of Nursing (employee #1) on 04/29/2025 at 1:30 PM she stated that residents arrive with instructions and a prescription from their orthopedic surgeon to continue treatment at the facility. The facility failed to provide evidence in the physician's progress notes justifying the use of this medication.

Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/28/2024 from 8:00 AM through 3:30 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect 15 out of 15 residents receiving services. Findings include: During observational tour at approximately 10:00 AM of April 28, 2025, two dirty linen carts were observed un attended in the extrerior patio area.

Based on observations of the physical environment and facility staff interview performed on 04/28/2025 from 8:00 AM through 3:30 PM, it was determined that the facility failed to maintain an effective pest control program so that the facility is free of pests. Findings include: 1. During the observations performed in the resident's rooms, the following was observed: a) On 04/28/2025 at 10:23 AM several spiders (3) were observed in room [ROOM NUMBER].

Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 04/22/2024 through 04/23/2024 to from 8:00 AM through 4:00 PM, it was determined that the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Findings include: During observational tour of kitchen on April 22, 2024, approximately at 8:52 AM, products such as cheese and meat were found unlabeled on the refrigerator.

Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/22/2024 through 04/23/2024 to from 8:00 AM through 5:00 PM, it was determined that the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. This deficient practice had the potential to affect 18 out of 18 residents receiving services at areas where the deficient environment and items. Findings include: 1. room [ROOM NUMBER] was observed detached from the wall behind bed and in bathroom. 2. Towel rack on room was found loose from the wall. 3. Chipped Formica was found chipped in most of the facility' rooms as detailed: 111 Bathroom door with chipped panel near doorknob 110 Chipped Formica on closets 109 Chipped Formica on night tables 108 Chipped Formica on night tables and closet of resident A and B 107 Chipped Formica on night tables and closet of resident A and B 106 Chipped Formica on night tables and closet of resident A and B 105. Chipped Formica on night tables and closet of resident A and B. Glue was observed on side of closet A 104. Chipped Formica on night tables and closet of resident A and B. Hinges on closets in need of repair 103. Chipped Formica on night table resident A 102. Chipped Formica on Closet A 101. Chipped Formica on closet resident B and night tables of resident A and B

Based on records reviewed (RR) and interview with the Minimum Data Set- MDS coordinator (employee #1) it was identified that the facility failed to transmit as required, MDS (Minimum Data Set) with review of health data and resident status in 1 out of 1 MDS record over 120 days old. Findings include: RR#11 is a [AGE] year-old female resident admitted [DATE] with a diagnosis of Right Hip Replacement. The resident admission was on 10/22/2023 and discharge home was on 11/01/2023. On 04/23/2024 at 10:35 AM in an interview with MDS Coordinator (employee #1) it was identified that the MDS discharge data was not transmitted when finished because of lack of assessment data of the physical therapy personnel. The case remain open and that is the reason why the case appears with an MDS record over 120 days old. She explains that the case must be coded and transmitted as an admission and as discharge both before being transmitted and this was not performed. MDS coding was corrected on 04/23/2024 and transmitted with the correction. Resident assessment validation and entry system report was reviewed

Based on an interview with the Minimum Data Set- (MDS) coordinator (employee #1), it was determined that the facility failed to accurately electronically transmit resident assessment instrument status correctly in 1 out of 2 closed records reviewed (RR). (Resident #2) Findings include: During the records reviewed the electronic system identified resident #2 as a hospitalization . On 04/23/24 at 1:30 PM during the record review it was found that Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Status post-surgery of Lumbar stenosis, in the record appears that resident #2 was a planned Discharge Home to the community due to completing goal and was discharged on [DATE] with appointment with primary physician and surgeon for follow up and continue treatment with home care for Physical Therapy Services for 10 days and Nursing Services for wound care. The MDS coordinator employee #1 interviewed on 04/23/2024 at 01:40 PM refer that this resident was discharged to the community, however when the information was enter to the system was document by error short-term general hospital. On 4/23/2024 at 3:01 PM she corrects this error and was transmitted correctly and accepted.

Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 04/22/2024 through 04/23/2024 to from 8:00 AM through 5:30 PM, it was determined that the facility failed to promote the resident right to receive services in a safe, clean, comfortable, and homelike environment. This deficient practice had the potential to affect 18 out of 18 residents receiving services. Findings include: 1. During observational tour at approximately 10:50 AM of April 22, 2024, it was observed that the weight in the shower area had rust in the base and other parts. 2. During observational tour at approximately 11:00 AM of April 22, 2024, it was observed that the wheelchair weight in the Recreational Therapy was found with excessive dust. 3. During observational tour at approximately 11:25 AM of April 22, 2024, it was observed that the grab bar on shower area was loose presenting a risk to patients taking a shower.

Based on the recertification/abbreviated and Extended survey, initial tour, record review and observations it was found that the facility failed to performed a risk for entrapment from bed rails prior to installation and failed to acquired manufacturer recommendation and specification for installing and maintaining bed rails resulting in an Immediate Jeopardy for 10 out of 19 resident beds. Findings include: 1. During the tour performed on 7/15/2021at 9:00 AM till 3:45 PM, it was observed that space from the mattress and the bed rails was 3 inches and the space from head/foot board was 7 inches for 10 out of 19 resident beds. (Rooms 101 A, 101 B, 102 A, 102 B, 104 A, 104 B, 107 A, 107B, 108 A and 108 B) 2. No documentation was found related to resident assessment/re-assessment for risk of entrapment from mattress and bed rails. 3. No documentation was provided related to bed manufacturing recommendation and specification. 4. Bed certification was requested to the institutional plan personnel on 7/16/2021 at 12:30 pm and not provided. Serious injury, or serious adverse outcome, is likely to occur due to bed rails use without been assessed, monitored and evaluated for the risk of entrapment. The facility needs to take immediate action to prevent the likelihood of possible serious injuries by entrapment in bed/rails. 5. The Immediate Jeopardy (IJ) was notify to the State Agency Coordinator on 07/16/2021 at 3:14 PM. 6. The IJ is notified to the facility's administrator on 07/16/2021 at 4:20 PM. 7. The facility provide to the surveyor a plan of correction on July 16, 2021 at 7:00PM as follow: The beds installed in the facility are Hill-Rom certified beds. Hill-Rom is a well-known manufacture of hospital beds. The facility has a biomedical contract with the company Ciracet to provide initial inspection and maintenance services. All beds were certified, and inspection was done October 29, 2020. The Safety Officer contracted by the facility performs monthly inspections of the beds and mattresses and reports any defects. The Physical Plant Supervisor will begin a daily inspection of the bedrails and mattresses on 7/16/2021. A register will be created to document the inspection. A quality indicator will be initiated to ensure the compliance, by 7/19/2021. The Administrator will ensure that the daily inspection is performed. The Purchasing Officer issued a Purchase Order #3837 to [NAME] Rico Hospital Supply for the purchase of 10 beds. The Sales Representative informed the beds will be delivered by the end of August. During the waiting period, until the new models are delivered, those residents assigned to the rooms with the older models' beds will be assesses daily for risk of entrapment. By 7/19/2021 the following will be accomplished: A policy and procedure will be developed to ensure the bed meets the resident's needs, the resident is assessed for the use of bed rails, which includes a review of risk including entrapment, and informed consent is obtain from resident and/or representative. A quality indicator will be initiated to ensure the beds meets the resident's needs. The Director of Nursing will provide training to the direct care staff regarding the policy and procedure developed. The procedure will include an assessment form to address the review of risk including the risk of entrapment and the informed consent. The registered nurse will assess the resident for risk of entrapment, upon admission and daily beginning on 7/16/2021. Those residents identified with risk of entrapment, will be assigned to a room with newer beds. 8. The Plan of Correction was accepted on 07/16/2021 at 7:30 PM. 9. On 07/19/2021 at 11:00 AM the IJ was lifted during an onsite verification of implementation of the correction plan that the facility performed.

Based on observation and interviews with the Medical Director (employee # 7), Visiting physician ( employee #6), Registered Nurse, (employee # 2) and pharmacist (employee # 14) at the facility performed on 5/20/15 from 4:30 pm thru 5:30 pm, it was determined that the facility fails to prevent residents from harm on 2 out of 4 residents. This constitutes an Immediate Jeopardy to the Residents Findings include: A lack of mechanism to ensure that the resident is free of medication errors of 5 % or greater and residents are free of any significant medication errors were observed as follows: 1. According to Medication Administration Record [REDACTED] a. Resident #1 the physician order establishes [MEDICATION NAME] 100 mgs 2 tablets by mouth at hours of sleep (HS) but the registered nurse was administrating since 5/12/15 [MEDICATION NAME] 100 mgs cap twice a day, no physicians order was found in the clinical record establishing that this medication will be given twice a day. During record review (performed on 5/20/15 at 9:00 am it was found that on nursing progress notes from 5/12/15 at 8:00 am, the resident had blood glucose results on 325 mgs/dl and the physician was consulted. The registered nurse wrote that administered [MEDICATION NAME] R 5 units subcutaneous (sq) but no physician ' s orders were found on the clinical record. b. Resident #6 the resident is receiving since 5/15/15 Montelukast 10 mgs tab by mouth daily, Laxapro 20 mgs tab by mouth daily, Folic Acid 1 mg tab by mouth daily and [MEDICATION NAME] 20 mgs tab by mouth daily but these medications were given without physicians orders. During the medication reconciliation review performed on 5/20/15 at 1: 00 pm it was found the resident brought from home [MEDICATION NAME] 50 mg tab by mouth daily. This medication is given by the nursing staff since 5/16/15 but no physician order was found. 2. After the drug pass procedure the facility obtained a 17.85 % on medication errors. 3. After interviewing the registered nurse who performed the drug pass, the pharmacist, the visiting physician and the medical director performed on 5/20/15 from 3:30 pm thru 5:30 pm it was found that the facility failed to have an ongoing surveillance to avoid near future adverse effects from medication administration.

Based on observation and interviews with the Medical Director (employee # 7), Visiting physician (employee #6), Registered Nurse,(employee # 2) and pharmacist (employee # 14) at the facility performed on 5/20/15 from 4:30 pm thru 5:30 pm, it was determined that the facility fails to prevent residents (R) from harm for 2 out of 4 residents (R#1 and #6). This constitutes an Immediate Jeopardy to the residents. Findings include: A lack of mechanism to ensure that the resident is free of medication errors of 5 % or greater and residents are free of any significant medication errors were observed as follows: 1. According to Medication Administration Record [REDACTED] a. Resident #1 the physician order [REDACTED]. b. Resident #6 the resident is receiving since 5/15/15 Montelukast 10 mgs tab by mouth daily, Laxapro 20 mgs tab by mouth daily, Folic Acid 1 mg tab by mouth daily and [MEDICATION NAME] 20 mgs tab by mouth daily but these medications were given without physicians orders. 2. After the drug pass procedure the facility obtained a 17.85 % on medication errors. 3. After interviewing the registered nurse who performed the drug pass, the pharmacist, the visiting physician and the medical director performed on 5/20/15 from 3:30 pm thru 5:30 pm it was found that the facility failed to have an ongoing surveillance to avoid near future adverse effects from medication administration.

Based on observation, individual interview and group interview, and record review during the recertification survey on 5/19/15 to 5/22/15, it was determine that the facility failed to ensure that resident (R) is free from physical restraints, unless needed to treat a medical symptom for 1 out of 8 residents in the sample (R#6). Findings include: A resident indicates she was threatened to be restraint with four side rails up if she does not follow instructions. Fall Risk care plan has side rails for safety measures. 1. Resident #6 is [AGE] years old female who was admitted for care on 5/15/15 with a [DIAGNOSES REDACTED]. During the group interview performed on 5/19/15 patients indicates that a register nurse threatened her to raise all four side rails if she does not follows instruction. Interview the resident on 5/19/15 at 4:30 pm she indicates she feels worried because she lives alone and does not have anybody who can help her. She feels sad because two times during the nights the register nurse said if she does not follow instructions she is going to raise the four side rails. Resident indicates that she was sitting in the border of the bed because she feels uncomfortable and her neck hurts. She says the doctor gave her instruction to do that when she felt pain because is a method to relieve the pain. Reviewing the facility protocol for side rails and restrains the document reveals that the patient has to be evaluated and the resident and family has to give the consent to maintain the four side rails raises. (Cross Reference Tag F323).

Based on eight records reviewed and interview with the physical therapy supervisor (employee #4) and review of accident reports, it was identified that the facility failed to promote that the environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents. Findings include: 1. A mechanism to ensure that appropriate instructions and guides in the use of assistive devices provided to a resident receiving physical therapy was not promoted in order to avoid an accident by the resident with the assistive device used to regain movement after knee surgery. The following findings were identified during the review of sample selection resident #4 with the physical therapy supervisor (employee #4) on 8/9/12 at 1:45 pm: a. Resident #4 is an [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During the initial observational tour on 8/9/12 at 9:30 am the resident stated that on 8/8/12 at 10:30 am during her physical therapy session she suffered an accident in the physical therapy area, where personnel accidentally hit her right knee surgery area with her walker. She said that she suffered pain and was afraid that her surgery was at risk due to the accident. b. When interviewed on 8/9/12 at 1:20 pm the physical therapy supervisor stated that she did not know how the resident received the trauma on her knee, that she interviewed the physical therapy assistant (PTA) involved in the accident. She stated that the PTA told her that when she finished with the physical therapy session of the resident, she looked for the resident's walker who was sitting on the therapy mattress, and when she put the walker in front of the resident she grab at it and the assistive device fell down on the resident's right knee surgery area. The physical therapy supervisor (employee #4) also stated that this physical therapy assistant (employee #10) always work under the direct supervision of herself who is always available at the physical therapy area. c. When the accident report was reviewed on 8/9/12 at 2:00 pm, it was found that the physical therapy supervisor who prepared the report stated that the resident did not follow instruction to wait until the walker was open and ready to use, and that after the trauma no changes were observed with the surgery site and that they applied cold packs to the area. d. On 8/9/12 at 11:00 am the resident's physician was informed about the accident and she ordered to transfer the resident to the hospital to take x-rays of the right knee for assessment of the surgery area. The resident was transferred to the hospital on [DATE] approximately at 3:00 pm by ambulance.

Based on eight records reviewed and interview and review of accident reports, it was identified that the facility failed to ensure that residents receive and the facility provides the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for one out of eight residents (resident #4). Findings include: 1. A mechanism to ensure that residents obtain optimal improvement within the limits of their rehabilitation goals and plan of care was not promoted nor followed. The following findings were identified during the review of the record for resident #4 with the physical therapy supervisor (employee #4) on 8/9/12 at 1:45 pm: a. Resident #4 is an [AGE] year old female admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. During the initial observational tour on 8/9/12 at 9:30 am the resident stated that on 8/8/12 at 10:30 am during her physical therapy session she suffered an accident in the physical therapy area, where personnel accidentally hit her right knee surgery area with her walker. She said that she suffered pain and was afraid that her surgery was at risk due to the accident. b. On 8/9/12 at 11:00 am the resident's physician was informed about the accident and she ordered to transfer the resident to the hospital to take x-rays of the right knee for assessment of the surgery area. The resident was transferred to the hospital on [DATE] approximately at 3:00 pm by ambulance. c. The facility failed to help the resident to regain movement as she experienced increase in pain experienced by the surgery and the accident.