SERVICIOS INTEGRADOS DE REHABILITACION (SIRO) INC

Nursing Home Inspector

CALLE 4-L-10 URB COLINAS DEL OESTE
HORMIGUEROS, PR 00660
Hormigueros County
Phone: 787-849-2179
Provider Number: 405029
Last Inspection: 05/18/2017

About the Nursing Home

Number of Beds: 19
Number of Residents: 14
Beds Available: 5
Percent Occupancy: 74%
Insurance Accepted: Medicare
Types of Councils: None
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

46

Facility
46

County
68

PR
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

46

2017
34

2016
139

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/18/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide clean bed and bath linens that are in good condition. Pattern : Minimal 4 7/13/2017
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Isolated : Minimal 3 7/13/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 7/13/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 7/13/2017
 
Failed To: Provide enough power supply for lighting all entrances and exits; equipment for fire detection and alarm systems, and extinguishers. Widespread : Minimal 5 7/13/2017
 
Failed To: Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Widespread : Minimal 5 7/13/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 7/13/2017
 
Failed To: Operate and provide services according to Federal, State, and local laws and professional standards. Widespread : Minimal 5 7/13/2017
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Widespread : Potential 4 7/13/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Widespread : Minimal 5 7/13/2017
 

2/25/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Widespread : Minimal 5 4/12/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Widespread : Minimal 5 4/12/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Widespread : Potential 4 4/12/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Actual 5 4/12/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Widespread : Minimal 5 4/12/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 4/12/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 4/12/2016
 

5/22/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Widespread : Minimal 5 7/9/2015
 
Failed To: Keep residents' personal and medical records private and confidential. Widespread : Minimal 5 7/9/2015
 
Failed To: Let residents voice a complaint or grievance without being treated differently or badly. Widespread : Minimal 5 7/9/2015
 
Failed To: Allow residents to have visitors. Widespread : Minimal 5 7/9/2015
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Actual 4 7/9/2015
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 7/9/2015
 
Failed To: Provide doctor's orders for the resident's immediate care at the time the resident was admitted. Pattern : Minimal 4 7/9/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 7/9/2015
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Widespread : Minimal 5 7/9/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Widespread : Minimal 5 7/9/2015
 
Failed To: Ensure residents maintain acceptable nutritional status. Pattern : Minimal 4 7/9/2015
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Pattern : Minimal 4 7/9/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Immediate 6 6/25/2015
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Immediate 6 6/25/2015
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Widespread : Minimal 5 7/9/2015
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 7/9/2015
 
Failed To: Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor. Widespread : Minimal 5 7/9/2015
 
Failed To: Provide routine and 24-hour emergency dental care for each resident. Widespread : Minimal 5 7/9/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Widespread : Minimal 5 7/9/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 7/9/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 7/9/2015
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 7/9/2015
 
Failed To: Operate and provide services according to Federal, State, and local laws and professional standards. Widespread : Minimal 5 7/9/2015
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Widespread : Minimal 5 7/9/2015
 
Failed To: Choose a doctor to serve as the medical director to create resident care policies and coordinate medical care in the facility. Widespread : Minimal 5 7/9/2015
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Widespread : Minimal 5 7/9/2015
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 7/9/2015
 
Failed To: Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care. Widespread : Minimal 5 7/9/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 7/9/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PR State Avg
Number of Residents 14 14.00 16.33
Registered Nurses 3.35 3.35 3.11
Licensed Practical / Vocational Nurses 3.40 3.40 1.98
Certified Nursing Assistants 0.00 Not Available 0.00
Total Staff Hours 6.75 6.75 5.08

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PR State Avg%
of short-stay residents assessed and appropriately given the pneumococcal vaccine 98 Not Available   Not Available  
of short-stay residents who had an outpatient emergency department visit 17 Not Available   100
of short-stay residents who made improvements in function 64 Not Available   Not Available  
of short-stay residents who newly received an antipsychotic medication 0 Not Available   0
of short-stay residents who self-report moderate to severe pain 79 Not Available   0
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 98 Not Available   Not Available  
of short-stay residents who were rehospitalized after a nursing home admission 0 Not Available   17
of short-stay residents who were successfully discharged to the community 100 Not Available   0
of short-stay residents with pressure ulcers that are new or worsened 0 Not Available   Not Available