Multy Medical Skilled Nursing Facility
Inspection history, citations, penalties and survey trends for this long-term care facility in Rio Piedras, PR.
- Location
- Americo Miranda Ave Entrada Principal Centro, Rio Piedras, PR 00935
- CMS Provider Number
- 405034
- Inspections on file
- 4
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Multy Medical Skilled Nursing Facility during CMS and state inspections, most recent first.
Medication Room Temperature and Humidity Not Maintained: The facility failed to keep the medication room within the required temperature and humidity ranges. Observation showed the room was below the temperature range and above the humidity limit, and log review showed repeated out-of-range readings over several months. The DON stated that no corrective actions were taken or documented.
Failure to submit PBJ staffing data to CMS. The DON stated she was not responsible for PBJ submission, and the Director of Compliance reported that PBJ reporting had previously been handled by the administrator before the administrator resigned. The facility had not submitted PBJ data and had recently become aware that no one had been assigned to continue the task.
The facility failed to use resident satisfaction survey data as part of its QAPI process. Survey review showed that resident experience information was collected on an ongoing basis, but the compliance officer stated it was not discussed in QAPI committee meetings or activities, and the facility did not align services with resident needs and expectations to identify areas for improvement.
QAPI committee meetings did not show participation by the Administrator, owner, board member, or other required leadership individual in each meeting. Review of meeting attendance and QAPI rules showed missing leadership involvement in the committee structure, and the QAPI compliance officer confirmed that leadership did not participate in every meeting.
Bathroom Water Escaping During Showers: Five residents reported that water came out of the bathroom while showering, and staff reportedly told residents to place bed sheets on the bathroom floor to limit the water. During observations of one resident, water was seen under the bed after showering, and even when a bed sheet was placed on the floor, water still escaped the bathroom.
Corridor handrails were found with loose corner sections and uneven surfaces that created irregular gripping areas near multiple rooms and the men visitors bathroom. An engineer confirmed the handrails were not in good repair and that no immediate corrective action had been taken at the time of survey.
Unsafe and Inaccessible Bathroom Environment: A resident admitted with a left TKR reported that the bathroom was uncomfortable and difficult to use. While using the bathroom with nursing assistance, she became entangled between her walker and the commode and slid to the floor, with staff unable to prevent the fall. An incident report was completed and the resident was evaluated by a physician.
The facility failed to retain posted daily nurse staffing information for the required 18-month period. When surveyors requested the prior staffing postings, the facility could only produce records from 10/01/2025 forward, and the DIT said attempts to retrieve earlier postings were unsuccessful.
Medication Room Temperature and Humidity Not Maintained
Penalty
Summary
The facility failed to ensure that the medication room maintained the temperature and relative humidity ranges required by its policy, which states the room temperature must be kept between 72 and 78 degrees Fahrenheit and relative humidity between 20% and 60%, with any out-of-range readings reported and documented with corrective actions. During an observation of the medication room, the temperature was 71.9 degrees Fahrenheit and the relative humidity was 72%. Review of the temperature and humidity logs from December 2025 through March 2026 showed repeated out-of-range readings, including January 2026 when the temperature was over 78 degrees Fahrenheit on 7 of 31 days and humidity was over 60% on 7 of 31 days, February 2026 when the temperature was over 78 degrees Fahrenheit on 2 of 28 days and humidity was over 60% on 3 of 28 days, and March 2026 when humidity was over 60% on 21 of 26 days. The DON stated that no corrective actions were taken or documented.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to ensure submission of Payroll-Based Journal (PBJ) data to CMS based on payroll and other verifiable and auditable data. During an interview on 03/25/2026, the DON stated that she was not responsible for completing and submitting PBJ. In a later interview, the Director of Compliance reported that PBJ reporting had been the responsibility of the administrator before the administrator's resignation, but PBJ data had not been submitted and the facility had recently become aware that no one had been assigned to continue this responsibility.
QAPI Did Not Use Resident Satisfaction Data
Penalty
Summary
The facility failed to consider resident feedback as quantifiable data within its QAPI process to enhance care and ensure safety. Review of QAPI activities for 2025 and the first quarter of 2026 showed that the administration clerk officer had collected resident satisfaction survey information during 2025, and the facility compliance officer stated that the facility collects resident experience information on an ongoing basis through a satisfaction survey questionnaire. However, he explained that this information was not discussed as part of QAPI committee meetings and activities. The report also states that the facility failed to align healthcare services with resident needs and expectations in order to identify areas for improvement.
QAPI Committee Lacked Required Leadership Participation
Penalty
Summary
The facility failed to maintain a QAPI committee with participation from the administrator, owner, a board member, or other individual in a leadership role during each committee meeting. Review of quarterly QAPI committee meetings for 2025 and 2026 showed that the January 14, 2026 meeting did not evidence participation by an administrator, owner, board member, or other leadership individual. The attendance list for the first quarter of 2025, covering January through March 2025, also did not demonstrate participation by any of these required leadership members. Review of the facility’s QAPI rules and regulations updated on 01/08/2026 did not include a requirement in the governance and leadership section that the Administrator or leadership personnel be part of the required QAPI committee members. During interview, the QAPI compliance officer stated that the administrator, owner, board member, or other individual in a leadership role did not participate in each committee meeting.
Bathroom Water Escaping During Showers
Penalty
Summary
The facility failed to provide a safe environment in the residents’ bathrooms in 5 of 16 residents interviewed. During initial pool interviews, residents 75, 76, 77, 78, and 79 stated that water came out of the bathroom when they were showering, and that nursing staff instructed residents to place bed sheets on the bathroom floor before showering so the water would not go out of the bathroom. During an observation of resident 76 on 03/25/2026 at 9:15 AM, the resident had just come out of the shower and water was noted under the bed from the bathroom while showering; a nurse asked whether the resident had placed a bed sheet on the floor before showering, and the resident had not. During another observation of resident 76 on 03/25/2026 at 8:10 AM, the resident was again getting out of the shower, had placed a bed sheet on the bathroom floor, and water was still observed to be out of the bathroom.
Corridor Handrails Not Maintained in Good Repair
Penalty
Summary
Handrails in the facility’s corridors were not maintained in good repair. During a tour on 03/26/2026, surveyors observed handrails with loose corner sections and handrails with uneven surfaces that created irregular gripping areas. These conditions were seen next to multiple rooms and next to the men visitors bathroom. The engineer (employee #3) confirmed that the handrails were not in good repair and stated that no immediate corrective action had been taken at the time of survey.
Unsafe and Inaccessible Bathroom Environment
Penalty
Summary
The facility failed to ensure a safe, comfortable, and adequately accessible bathroom environment for one sampled resident. The resident, a 59-year-old female admitted with a diagnosis of left total knee replacement, reported during interview that the bathroom space was very uncomfortable and difficult to use. She stated that while using the bathroom with assistance from nursing staff, she became entangled between her walker and the commode and slid to the floor. She further reported that staff attempted to help her remain standing but were unable to prevent the fall. Facility documentation showed that an incident/accident report was completed for the event and that the resident was evaluated by a physician afterward.
Failure to Retain Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to retain posted daily nurse staffing information for the required retention period of at least 18 months. On 03/25/2026 at 3:15 PM, surveyors requested the facility’s posted daily nurse staffing information for the previous 18 months, but the facility could only provide documentation from 10/01/2025 to the present. During an interview on 03/25/2026, the Director of Information Technology stated that attempts were made to retrieve prior staffing postings, but those efforts were unsuccessful.
Latest citations in PR
Medication Room Temperature and Humidity Not Maintained: The facility failed to keep the medication room within the required temperature and humidity ranges. Observation showed the room was below the temperature range and above the humidity limit, and log review showed repeated out-of-range readings over several months. The DON stated that no corrective actions were taken or documented.
Failure to submit PBJ staffing data to CMS. The DON stated she was not responsible for PBJ submission, and the Director of Compliance reported that PBJ reporting had previously been handled by the administrator before the administrator resigned. The facility had not submitted PBJ data and had recently become aware that no one had been assigned to continue the task.
The facility failed to use resident satisfaction survey data as part of its QAPI process. Survey review showed that resident experience information was collected on an ongoing basis, but the compliance officer stated it was not discussed in QAPI committee meetings or activities, and the facility did not align services with resident needs and expectations to identify areas for improvement.
QAPI committee meetings did not show participation by the Administrator, owner, board member, or other required leadership individual in each meeting. Review of meeting attendance and QAPI rules showed missing leadership involvement in the committee structure, and the QAPI compliance officer confirmed that leadership did not participate in every meeting.
Bathroom Water Escaping During Showers: Five residents reported that water came out of the bathroom while showering, and staff reportedly told residents to place bed sheets on the bathroom floor to limit the water. During observations of one resident, water was seen under the bed after showering, and even when a bed sheet was placed on the floor, water still escaped the bathroom.
Corridor handrails were found with loose corner sections and uneven surfaces that created irregular gripping areas near multiple rooms and the men visitors bathroom. An engineer confirmed the handrails were not in good repair and that no immediate corrective action had been taken at the time of survey.
Unsafe and Inaccessible Bathroom Environment: A resident admitted with a left TKR reported that the bathroom was uncomfortable and difficult to use. While using the bathroom with nursing assistance, she became entangled between her walker and the commode and slid to the floor, with staff unable to prevent the fall. An incident report was completed and the resident was evaluated by a physician.
The facility failed to retain posted daily nurse staffing information for the required 18-month period. When surveyors requested the prior staffing postings, the facility could only produce records from 10/01/2025 forward, and the DIT said attempts to retrieve earlier postings were unsuccessful.
Kitchen sink sanitization temperatures and refrigerator temperatures were not maintained as required. The washing sink was documented below the required 110°F on multiple occasions without documented corrective action, and several refrigerators were repeatedly recorded above the expected temperature range, including one unit observed at 48°F during a kitchen tour. The kitchen dietitian stated staff had contacted maintenance about the equipment, but no appointment confirmation was provided.
A pharmacist’s medication regimen review was not documented in the clinical record for multiple residents, despite facility policy requiring review of the MAR, physician orders, and med reconciliation shortly after admission. Records for three residents lacked the required documentation, and another resident admitted with a hip replacement had orders for Keflex and Tylenol with Codeine, but no documented pharmacist MRR was found.
Medication Room Temperature and Humidity Not Maintained
Penalty
Summary
The facility failed to ensure that the medication room maintained the temperature and relative humidity ranges required by its policy, which states the room temperature must be kept between 72 and 78 degrees Fahrenheit and relative humidity between 20% and 60%, with any out-of-range readings reported and documented with corrective actions. During an observation of the medication room, the temperature was 71.9 degrees Fahrenheit and the relative humidity was 72%. Review of the temperature and humidity logs from December 2025 through March 2026 showed repeated out-of-range readings, including January 2026 when the temperature was over 78 degrees Fahrenheit on 7 of 31 days and humidity was over 60% on 7 of 31 days, February 2026 when the temperature was over 78 degrees Fahrenheit on 2 of 28 days and humidity was over 60% on 3 of 28 days, and March 2026 when humidity was over 60% on 21 of 26 days. The DON stated that no corrective actions were taken or documented.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to ensure submission of Payroll-Based Journal (PBJ) data to CMS based on payroll and other verifiable and auditable data. During an interview on 03/25/2026, the DON stated that she was not responsible for completing and submitting PBJ. In a later interview, the Director of Compliance reported that PBJ reporting had been the responsibility of the administrator before the administrator's resignation, but PBJ data had not been submitted and the facility had recently become aware that no one had been assigned to continue this responsibility.
QAPI Did Not Use Resident Satisfaction Data
Penalty
Summary
The facility failed to consider resident feedback as quantifiable data within its QAPI process to enhance care and ensure safety. Review of QAPI activities for 2025 and the first quarter of 2026 showed that the administration clerk officer had collected resident satisfaction survey information during 2025, and the facility compliance officer stated that the facility collects resident experience information on an ongoing basis through a satisfaction survey questionnaire. However, he explained that this information was not discussed as part of QAPI committee meetings and activities. The report also states that the facility failed to align healthcare services with resident needs and expectations in order to identify areas for improvement.
QAPI Committee Lacked Required Leadership Participation
Penalty
Summary
The facility failed to maintain a QAPI committee with participation from the administrator, owner, a board member, or other individual in a leadership role during each committee meeting. Review of quarterly QAPI committee meetings for 2025 and 2026 showed that the January 14, 2026 meeting did not evidence participation by an administrator, owner, board member, or other leadership individual. The attendance list for the first quarter of 2025, covering January through March 2025, also did not demonstrate participation by any of these required leadership members. Review of the facility’s QAPI rules and regulations updated on 01/08/2026 did not include a requirement in the governance and leadership section that the Administrator or leadership personnel be part of the required QAPI committee members. During interview, the QAPI compliance officer stated that the administrator, owner, board member, or other individual in a leadership role did not participate in each committee meeting.
Bathroom Water Escaping During Showers
Penalty
Summary
The facility failed to provide a safe environment in the residents’ bathrooms in 5 of 16 residents interviewed. During initial pool interviews, residents 75, 76, 77, 78, and 79 stated that water came out of the bathroom when they were showering, and that nursing staff instructed residents to place bed sheets on the bathroom floor before showering so the water would not go out of the bathroom. During an observation of resident 76 on 03/25/2026 at 9:15 AM, the resident had just come out of the shower and water was noted under the bed from the bathroom while showering; a nurse asked whether the resident had placed a bed sheet on the floor before showering, and the resident had not. During another observation of resident 76 on 03/25/2026 at 8:10 AM, the resident was again getting out of the shower, had placed a bed sheet on the bathroom floor, and water was still observed to be out of the bathroom.
Corridor Handrails Not Maintained in Good Repair
Penalty
Summary
Handrails in the facility’s corridors were not maintained in good repair. During a tour on 03/26/2026, surveyors observed handrails with loose corner sections and handrails with uneven surfaces that created irregular gripping areas. These conditions were seen next to multiple rooms and next to the men visitors bathroom. The engineer (employee #3) confirmed that the handrails were not in good repair and stated that no immediate corrective action had been taken at the time of survey.
Unsafe and Inaccessible Bathroom Environment
Penalty
Summary
The facility failed to ensure a safe, comfortable, and adequately accessible bathroom environment for one sampled resident. The resident, a 59-year-old female admitted with a diagnosis of left total knee replacement, reported during interview that the bathroom space was very uncomfortable and difficult to use. She stated that while using the bathroom with assistance from nursing staff, she became entangled between her walker and the commode and slid to the floor. She further reported that staff attempted to help her remain standing but were unable to prevent the fall. Facility documentation showed that an incident/accident report was completed for the event and that the resident was evaluated by a physician afterward.
Failure to Retain Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to retain posted daily nurse staffing information for the required retention period of at least 18 months. On 03/25/2026 at 3:15 PM, surveyors requested the facility’s posted daily nurse staffing information for the previous 18 months, but the facility could only provide documentation from 10/01/2025 to the present. During an interview on 03/25/2026, the Director of Information Technology stated that attempts were made to retrieve prior staffing postings, but those efforts were unsuccessful.
Kitchen Sink and Refrigerator Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to comply with required sink compartment sanitations and refrigerator temperatures during observations of the kitchen, review of policies and procedures, review of daily kitchen temperature logs, and staff interviews. During review of the three-compartment sink temperature log for March 2026, the washing sink temperatures were documented below the required 110°F on 03/05/2026 at 108°F and on 03/06/2026 at 109°F and 108°F, with no corrective action documented. The report also noted that refrigerator #1 measured 48°F during a kitchen tour on 03/10/2026 at 10:40 AM. Review of the March 2026 refrigerator temperature logs showed repeated temperatures above the expected range in refrigerator #1, refrigerator #2, and refrigerator #3. Refrigerator #1 was documented at 43°F to 49°F on multiple dates, refrigerator #2 was documented at 42°F to 44°F on several dates, and refrigerator #3 was documented at 42°F to 44°F on multiple dates. During an interview on 03/11/2026, the kitchen dietitian stated that staff became aware the equipment was not providing the required temperatures and had communicated with the maintenance company to request verification and maintenance of the equipment, but no appointment confirmation was provided.
Pharmacist Medication Regimen Reviews Not Documented
Penalty
Summary
The facility failed to ensure that a licensed pharmacist completed and documented a monthly drug regimen review in the clinical record, including review of the medical chart, in accordance with the facility’s policy and procedures. The policy reviewed stated that the pharmacist is responsible for conducting a medication regimen review upon a resident’s admission to the facility, using the medication reconciliation, physician orders, and the MAR, and that the review should be completed within approximately 72 hours of admission. During record review, the medical records for Resident #33, Resident #35, and Resident #25 did not contain documentation of the pharmacist’s medication regimen review as required by facility policy. In addition, Resident Sample #26, admitted with a diagnosis of right total hip replacement, had physician admission orders for Keflex 500 mg PO every 6 hours for 4 doses and Tylenol with Codeine 1-2 tablets every 4 hours for pain, but the pharmacist’s medication regimen review for this case, which involved opioids and antibiotics, was not found documented in the medical record.
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