SAN GERARDO HOSP - RIO PIEDRAS, PR

Complaint Deficiency

• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Some
• Proper medical gas storage and administration areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Many
• Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Two separate exits in rooms of more than 1000 square feet
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Approved construction type or materials
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Proper medical gas storage and administration areas
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Many
• Keep signed and dated reports of x-rays and other diagnostic services
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Check and assess each resident's assessment at least every 3 months
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Many
• Fire-resistant room wall surfaces
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Some
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Protected exits that allow the resident to escape the building
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Emergency lighting that can last at least 1 1/2 hours
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A fire alarm system that can be heard throughout the facility
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Outside doors or windows in every resident room
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Honor all of the resident's rights as a resident of the nursing home, free of coercion and reprisal, and as a citizen or resident of the United States
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep each resident's personal and medical records private and confidential
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Provide access to a telephone for resident to use in private
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Provide adequate and comfortable lighting levels in all areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Maintain comfortable and safe temperature levels
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have enough nurses to care for every resident in a way that maximizes the resident's well being
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Hire sufficient dietary support personnel
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that a working call system is available in each resident's room or bathroom and bathing area
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Have enough outside ventilation via a window or mechanical ventilation, or both
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Emergency lighting that can last at least 1 1/2 hours
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Did not have a written emergency evacuation plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A fire alarm system that can be heard throughout the facility
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Portable fire extinguishers
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Many
• Provide adequate and comfortable lighting levels in all areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Maintain comfortable and safe temperature levels
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Many
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Some
• Give each resident enough fluids to keep them healthy and prevent dehydration
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Some
• Have enough nurses to care for every resident in a way that maximizes the resident's well being
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Many
• Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Dispose of garbage and refuse properly
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Be licensed under State and local laws
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Many
• Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Some
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A fire alarm system that can be heard throughout the facility
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Honor all of the resident's rights as a resident of the nursing home, free of coercion and reprisal, and as a citizen or resident of the United States
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Keep each resident's personal and medical records private and confidential
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Allow residents to easily view the results of the nursing home's most recent survey
  • Harm: Potential for minimal harm
  • Scope: Many
• Determine if it is safe for the resident to self-administer drugs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide adequate and comfortable lighting levels in all areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Maintain comfortable and safe temperature levels
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Allow the resident the right to participate in the planning or revision of the resident's care plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Give each resident enough fluids to keep them healthy and prevent dehydration
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• 1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Develop policies and procedures for influenza and pneumococcal immunizations
  • Harm: Potential for minimal harm
  • Scope: Many
• Have enough nurses to care for every resident in a way that maximizes the resident's well being
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Post nurse staffing information/data on a daily basis
  • Harm: Potential for minimal harm
  • Scope: Many
• Hire sufficient dietary support personnel
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Dispose of garbage and refuse properly
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Actual harm
  • Scope: Many
• Be designed, built, equipped, or well kept to protect the health and safety of residents, workers, and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
  • Harm: Actual harm
  • Scope: Many
• Be administered in an acceptable way that maintains the well-being of each resident
  • Harm: Actual harm
  • Scope: Many
• Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many

Staff Information

Outcome of Care

Average Medicare Payment

Quality Measures