Servicios Integrados De Rehabilitacion (siro) Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Hormigueros, PR.
- Location
- Calle 4-l-10 Urb Colinas Del Oeste, Hormigueros, PR 00660
- CMS Provider Number
- 405029
- Inspections on file
- 18
- Latest survey
- March 11, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Servicios Integrados De Rehabilitacion (siro) Inc during CMS and state inspections, most recent first.
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 reconciliation forms for two residents lacked the pharmacist's review and signature. Both residents were admitted with a dx of right total knee replacement, and clinical record review showed the missing documentation in each chart.
Medication cart drawers assigned to several rooms could be opened even when the cart was in the locked position. During a tour of the med storage area, an RN observed that drawers for rooms 107 B, 108 A, 108 B, and 109 were accessible despite the cart being locked. An LPN reported that a defective equipment report had been completed for the cart and that Unicare had provided a repair quote.
A resident with sleep apnea had her personal apnea machine at the bedside, and staff stated it had been inspected after admission. However, when the equipment was later observed, there was no seal showing the inspection had been completed as required by facility policy.
Survey results and related information were not kept current or readily accessible at the nurse station. The posted survey dates were outdated, and although the facility had a more recent recertification survey, the most recent Medicare recertification survey and any plan of correction were not included or provided for review.
Failure to formally designate a charge nurse on each shift. The MDS Coordinator stated that the RN assigned to each shift was also the charge nurse, but review of the staff work assignment showed no formal designation of the RN as Charge Nurse or identification of charge nurse duties such as staff supervision, emergency coordination, physician liaison, or direct resident care.
The facility failed to accurately transmit the assessment status for two residents, resulting in incorrect documentation of a community discharge as a hospital transfer in one case, and a hospitalization as a home discharge in another. These errors were identified during record review and confirmed by the MDS coordinator.
Surveyors observed that chicken was stored in the freezer in a broken package with exposed parts, staff did not properly air dry utensils after sanitizing, and the kitchen supervisor was present near the food serving area without a hairnet.
Staff were observed failing to perform hand hygiene and use gloves when required, including during the placement of ice packs on a resident and during medication administration. Facility policies for these procedures did not include hand washing or glove use requirements, and these deficiencies were confirmed through staff interviews and policy review.
The facility did not provide ongoing education to physicians and nursing staff on appropriate antibiotic use, despite having written stewardship policies in place. Reports to the Department of Health showed prolonged antibiotic use in residents without documented justification, and the facility's monitoring lacked necessary detail.
Surveyors identified water damage and humidity in a bathroom ceiling and bed area, as well as condensation from air conditioning vents causing water to accumulate on the floor near an exit door. These issues created a slip and fall risk and affected all residents in the impacted areas.
Two dirty linen carts were found unattended in the exterior patio area, resulting in a failure to maintain a safe, clean, and homelike environment for all residents receiving services.
Several residents who had undergone right total knee replacement were prescribed antibiotics upon admission, but the facility did not provide documentation in physician progress notes to justify the continued use of these medications. The DON confirmed that residents arrived with prescriptions from their surgeons, yet the necessary clinical justification was missing from the records.
Surveyors observed several spiders in a resident's room, indicating the facility did not maintain an effective pest control program. This deficiency was identified during an inspection of the physical environment and staff interviews.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During a kitchen tour, products such as cheese and meat were found unlabeled in the refrigerator.
The facility failed to provide a safe, functional, sanitary, and comfortable environment, with issues such as a room detached from the wall, a loose towel rack, and chipped Formica in various rooms. These deficiencies had the potential to affect all 18 residents receiving services in the affected areas.
The facility failed to transmit the MDS assessment data within the required 7-day period for a resident admitted with a Right Hip Replacement. The delay was due to missing assessment data from physical therapy personnel, resulting in an MDS record over 120 days old.
A facility failed to accurately transmit the resident assessment status for a resident who was discharged home after lumbar stenosis surgery. The resident was incorrectly documented as being discharged to a hospital, which was later corrected by the MDS coordinator.
The facility failed to ensure a safe, clean, and homelike environment for its residents. Observations revealed rust on the weight in the shower area, excessive dust on the wheelchair weight in Recreational Therapy, and a loose grab bar in the shower area, potentially affecting all 18 residents.
The facility failed to provide a designated person to serve as the director of food and nutrition services. During observations and an interview with a TSA, it was revealed that the facility did not have a Diet Department Manager. The TSA was later designated as the Diet Department Manager, potentially affecting 18 residents.
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.
Missing Pharmacist Review and Signature on Medication Reconciliation
Penalty
Summary
The facility failed to ensure that medication reconciliation included the pharmacist's review and signature in the clinical record for 2 of 8 residents reviewed. Resident #33, a [AGE]-year-old female admitted with a diagnosis of right total knee replacement, had a medication reconciliation form in the medical record that lacked documentation of the pharmacist's review and signature during a clinical record review on 03/11/2026 at 11:29 AM. Resident #35, a [AGE]-year-old male admitted with a diagnosis of right total knee replacement, also had a medication reconciliation form that lacked documentation of the pharmacist's review and signature during a clinical record review on 03/11/2026 at 10:48 AM.
Medication Cart Drawers Could Be Opened While Cart Was Locked
Penalty
Summary
Medication carts were not properly secured to prevent unauthorized access to medications. During a tour of the medication storage area, it was observed that the medication cart drawers assigned to rooms 107 B, 108 A, 108 B, and 109 could be opened even though the medication cart was in the locked position. A Charge Nurse stated that a defective equipment report had been completed for the medication cart and that a representative from Unicare had visited the facility and provided a quotation for repair services. After the observation, the medications from those drawers were relocated to other secured compartments of the medication cart where the drawers could not be opened and the medications remained under staff custody.
Unsealed Resident Apnea Machine
Penalty
Summary
The facility failed to assure that mechanical, electrical, and patient care equipment were maintained in safe operating condition. Facility policy, "Protocolo uso de equipo electrico en cuarto de los residentes" (March 2024 revision), states that every piece of equipment brought by a patient will be inspected by physical plant personnel and then sealed. During a round on 3/10/2026, Resident #25, a female admitted with a diagnosis of right total knee replacement, was observed in room [ROOM NUMBER]-A with an apnea machine at the head of the bed. The resident stated she had sleep apnea and brought her own machine to the facility, which staff had inspected. When the surveyor observed the equipment on 3/11/2026, there was no seal indicating the inspection had been completed as required by facility policy.
Survey Results and Plan of Correction Not Posted
Penalty
Summary
The facility failed to ensure that survey results and related information were posted and readily accessible to residents, family members, and legal representatives. During an observation at the front of the nursing station, the posted results of the most recent surveys were dated 04/23/2024, 04/05/2023, and 05/05/2023, even though the facility’s last recertification survey had been conducted on 04/29/2025. In an interview on 03/11/2026, the MDS coordinator and CEO stated that an updated report reflecting the most recent recertification surveys, any certifications, complaint investigations from the preceding 3 years, and any plan of correction in effect must be available for review, but the most recent Medicare recertification survey and plan of correction were not included or provided.
Failure to Formally Designate a Charge Nurse on Each Shift
Penalty
Summary
The facility failed to ensure that a charge nurse was formally designated on each shift to carry out the responsibilities assigned by the facility. During an interview, the MDS Coordinator stated that the RN assigned to each shift was also the charge nurse. However, review of the staff work assignment for the three working shifts on 3/10/26 and 3/11/26 showed that the document did not formally designate the RN as a Charge Nurse or identify specific charge nurse responsibilities, including staff supervision, emergency coordination, physician liaison duties, and direct resident care.
Inaccurate Electronic Transmission of Resident Assessment Status
Penalty
Summary
The facility failed to accurately transmit the resident assessment instrument status for two residents, resulting in incorrect documentation in the electronic system. In the first case, a female resident admitted for a left total knee replacement was discharged to home with home care and medical equipment. However, her discharge was incorrectly entered into the system as a transfer to a short-term general hospital, rather than a community discharge, as indicated in the MDS Section A A0310 F. This error was identified during a record review and confirmed by the MDS coordinator. In the second case, a male resident admitted for a right total knee replacement was transferred to the hospital due to suspected kidney failure. Despite the transfer being a hospitalization, the electronic system incorrectly documented the discharge as a return home. The MDS coordinator acknowledged the error during an interview. Both cases demonstrate failures in accurately transmitting resident assessment data, as required.
Deficiencies in Food Storage, Preparation, and Service Standards
Penalty
Summary
During an observational tour of the kitchen, surveyors identified several deficiencies related to food storage, preparation, and service. Chicken pieces were found in the freezer in a broken, sealed package with some parts exposed outside the wrapping and only covered in plastic wrap; kitchen staff stated the chicken was received from the supplier in that condition. Additionally, staff were seen using a scoop to serve rice and did not follow the proper process for sanitizing utensils, specifically failing to allow the utensil to air dry after sanitizing. The kitchen supervisor was also observed near the food serving area without wearing a hairnet.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene and glove use by staff. During rounds in resident rooms, a physical therapy assistant was seen entering a resident's room and placing ice packs on the resident without washing hands or wearing gloves. Review of the facility's policy for cold compress placement revealed that it did not include requirements for hand washing or glove use. Additionally, during a medication pass, a registered nurse did not wash her hands on four out of ten opportunities before entering five different resident rooms. These observations were confirmed through staff interviews and policy review.
Lack of Antibiotic Stewardship Education and Monitoring
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program that promotes appropriate antibiotic use and provides education to nursing and medical staff. During an interview with the Infection Control coordinator, it was revealed that while the facility maintains policies and procedures regarding antibiotic stewardship, including information on dosage, indication, renal adjustment, administration, precaution, monitoring, and dilution and stability, there is no ongoing educational program for physicians and nursing professionals on the appropriate use of antibiotics. Additionally, reports sent to the Puerto Rico Department of Health document the monthly volume of patients using antibiotics but lack specificity and do not justify prolonged antibiotic use in residents.
Environmental Safety and Sanitation Deficiencies Identified
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. During the inspection, water damage and humidity were noted on the bathroom ceiling and in the bed area of a specific room. Additionally, condensation on air conditioning vents resulted in water drops wetting the floor in front of the exit door to the back patio, creating a slip and fall risk. These environmental deficiencies were present in areas where all 18 residents receiving services could be affected.
Unattended Dirty Linen Carts Compromise Clean and Homelike Environment
Penalty
Summary
Surveyors observed that two dirty linen carts were left unattended in the exterior patio area during an observational tour. This occurred on April 28, 2024, at approximately 10:00 AM. The facility's failure to properly manage and store soiled linens resulted in a physical environment that was not maintained in a safe, clean, comfortable, and homelike manner for residents. This deficiency had the potential to affect all 15 residents receiving services at the time of the survey.
Lack of Documentation for Antibiotic Use in Post-Surgical Residents
Penalty
Summary
The facility failed to ensure that each resident's medication regimen was free from unnecessary drugs, specifically antibiotics, for several residents who had undergone right total knee replacement. Medical record reviews revealed that multiple residents were prescribed antibiotics such as Augmentin, Cipro, and Keflex upon admission, with orders originating from their orthopedic surgeons. However, there was no documentation in the physician's progress notes to justify the continued use of these antibiotics. The nursing staff's documentation in the care plans was limited to observations of the surgical site, such as the presence of a surgical patch and edema, without further clinical justification for antibiotic therapy. Interviews with the Director of Nursing confirmed that residents typically arrived with prescriptions and instructions from their surgeons, but the facility did not provide evidence in the medical records to support the necessity of these medications. This lack of documentation affected at least three residents, as identified in the survey, and was observed during a review of eight medical records. The deficiency was based on the absence of physician progress notes justifying the use of antibiotics for these residents.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of several spiders observed in a resident's room during an environmental inspection. This observation was made during a survey conducted on 04/28/2025, where three spiders were specifically noted in one of the resident rooms. The deficiency was identified through direct observation of the physical environment and interviews with facility staff. No additional information regarding the medical history or condition of the resident(s) in the affected room was provided in the report.
Failure to Adhere to Food Service Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observational tour of the kitchen, products such as cheese and meat were found unlabeled in the refrigerator. This observation was made on April 22, 2024, at approximately 8:52 AM. The deficiency was identified based on observations, review of policies and procedures, and staff interviews conducted from April 22, 2024, through April 23, 2024, between 8:00 AM and 4:00 PM.
Environmental Deficiencies in Facility
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed multiple deficiencies, including a room detached from the wall behind the bed and in the bathroom, a loose towel rack, and chipped Formica in various rooms. Specific rooms with chipped Formica included rooms 111, 110, 109, 108, 107, 106, 105, 104, 103, 102, and 101, affecting night tables, closets, and bathroom doors. Additionally, glue was observed on the side of closet A in room 105, and hinges on closets in room 104 were in need of repair. These deficiencies had the potential to affect all 18 residents receiving services in the affected areas.
Failure to Transmit MDS Assessment Data Timely
Penalty
Summary
The facility failed to transmit the Minimum Data Set (MDS) assessment data within the required 7-day period. This deficiency was identified during a review of records and an interview with the MDS Coordinator. Specifically, the MDS discharge data for a female resident who was admitted with a diagnosis of Right Hip Replacement and later discharged home was not transmitted on time. The delay occurred because the physical therapy personnel did not provide the necessary assessment data, leaving the case open and resulting in an MDS record that was over 120 days old.
Incorrect Electronic Transmission of Resident Assessment
Penalty
Summary
The facility failed to accurately electronically transmit the resident assessment instrument status for one out of two closed records reviewed. Specifically, a resident who was a [AGE] year-old female admitted with a diagnosis of status post-surgery of lumbar stenosis was incorrectly documented as being discharged to a short-term general hospital instead of being discharged home to the community. This error was identified during a record review on 04/23/24. The resident had completed her goals and was discharged with follow-up appointments and home care services arranged. The MDS coordinator acknowledged the error during an interview and subsequently corrected it in the system.
Failure to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to promote the resident's right to receive services in a safe, clean, comfortable, and homelike environment. During an observational tour, it was noted that the weight in the shower area had rust on the base and other parts. Additionally, the wheelchair weight in the Recreational Therapy area was found with excessive dust. Furthermore, the grab bar in the shower area was observed to be loose, presenting a risk to patients taking a shower. These deficiencies had the potential to affect all 18 residents receiving services at the facility.
Lack of Designated Director of Food and Nutrition Services
Penalty
Summary
The facility failed to provide a designated person to serve as the director of food and nutrition services. This deficiency was identified during observations and an interview with the TSA (employee #2) conducted from 04/22/2024 to 04/23/2024. The TSA stated that the facility did not have a Diet Department Manager. On 04/23/2024, surveyors were informed that TSA (employee #2) was designated as the Diet Department Manager. This practice had the potential to affect 18 admitted residents.
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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