Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
139 residents
Based on a May 2025 inspection.
Occupancy over time
Inspection Report
Routine
Census: 139
Deficiencies: 3
Date: May 15, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including PASARR screening for mental disorders or intellectual disabilities, quality assurance processes, and infection prevention and control procedures.
Findings
The facility failed to ensure accurate PASARR Level I and Level II screenings for residents, demonstrated repeated deficient practices related to PASARR screening, and failed to consistently follow infection prevention and control procedures regarding the storage of Incentive Spirometers for residents.
Deficiencies (3)
Failed to ensure residents received an accurate PASARR Level I screening and a Level II screening for one resident.
Quality assurance and assessment committee failed to implement an effective plan of action to correct repeated deficient practice related to PASARR screening.
Failed to follow infection prevention and control procedures for storage of Incentive Spirometers for residents.
Report Facts
Residents affected: 139
Residents affected: 1
Residents affected: 4
QAA Committee meetings: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding PASARR Level I completion and screening deficiencies |
| Administrator | Nursing Home Administrator (NHA) | Interviewed regarding QAA Committee and quality improvement processes |
| Licensed Practical Nurse Staff A | Licensed Practical Nurse | Interviewed regarding Incentive Spirometer storage and cleaning procedures |
| Licensed Practical Nurse Staff B | Licensed Practical Nurse | Interviewed regarding Incentive Spirometer storage and cleaning procedures |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Interviewed regarding Incentive Spirometer use and cleaning procedures |
Inspection Report
Routine
Census: 135
Deficiencies: 3
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to assess compliance with PASARR screening requirements and other regulatory standards related to resident care and safety.
Findings
The facility failed to ensure accurate completion and revision of PASARR screenings for four residents, failed to provide adequate supervision for a resident smoking unsupervised, and failed to maintain accurate narcotic counts and secure medication storage.
Deficiencies (3)
Failed to ensure a level 1 Preadmission Screening and Resident Review (PASARR) was completed accurately prior to admission and failed to revise the screening following admission for four residents.
Failed to ensure the safety of vulnerable residents for smoking; Resident #88 was smoking unsupervised in the smoking area.
Failed to ensure an accurate count on the narcotic sheet and failed to ensure medications were securely stored; four loose medication pills found on two carts.
Report Facts
Residents affected by PASARR deficiency: 4
Total residents at facility: 135
Residents who smoke: 7
Narcotic count discrepancy: 1
Loose medication pills found: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff B | Certified Nurse Assistant | Mentioned as responsible for supervising residents in the smoking area. |
| Staff C | Registered Nurse | Involved in narcotic count discrepancy and medication administration. |
| Staff E | Registered Nurse | Observed loose medication pills on medication cart and described medication cart cleaning procedures. |
| Director of Nursing | Provided information about PASARR process, narcotic count procedures, and medication cart maintenance. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 3, 2023
Visit Reason
The inspection was conducted as an annual survey of Ponce Health and Rehabilitation Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Census: 140
Deficiencies: 7
Date: Oct 20, 2022
Visit Reason
The inspection was conducted as part of the annual survey of Ponce Health and Rehabilitation Center to assess compliance with regulatory requirements related to resident care, medication administration, nutrition, respiratory care, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to ensure privacy of residents' medical records, inadequate assistance with activities of daily living, insufficient nutrition monitoring and support, improper tube feeding administration, inadequate tracheostomy care, medication error rates exceeding 5%, and improper medication storage and security.
Deficiencies (7)
Failed to ensure privacy of confidential information by leaving unlocked unattended computer screens with residents' information visible on medication carts.
Failed to provide care and assistance for activities of daily living related to grooming of a resident's fingernails.
Failed to perform appropriate nutrition monitoring and provide assistance during dining for a resident with a stage two pressure ulcer and poor oral intake.
Failed to assure that enteral nutrition was followed according to practitioner's order for tube feeding.
Failed to perform adequate tracheostomy care for a resident with tracheostomy, including improper use of sterile gloves and sequence of care steps.
Failed to ensure medication error rate was less than 5%, with an 11.88% error rate for medication administration of Oxycodone/Acetaminophen for one resident.
Failed to ensure proper storage of medications by leaving medication carts unlocked and unattended and failing to connect medication refrigerators to emergency electrical outlets.
Report Facts
Residents affected: 140
Medication error rate: 11.88
Medication administration opportunities: 682
Medication administration errors: 81
Tube feeding rate: 65
Tube feeding hours: 20
Pressure ulcer size: 0.8
Pressure ulcer size: 1.8
Protein needs: 67
Protein needs: 78
Protein intake average: 41
Protein intake percentage: 52
Protein intake percentage: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Registered Nurse | Named in privacy deficiency for leaving computer screens unattended and unlocked |
| Staff J | Registered Nurse | Named in privacy deficiency for leaving computer screens unattended and unlocked |
| Staff C | Certified Nursing Assistant | Named in deficiency related to failure to trim resident's fingernails |
| Staff D | Licensed Practical Nurse | Interviewed regarding wound care and nutrition |
| Staff E | Registered Nurse | Interviewed regarding wound care and nutrition |
| Staff F | Registered Nurse | Involved in tracheostomy care observation |
| Staff G | Registered Nurse | Involved in tracheostomy care observation |
| Staff K | Registered Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff L | Registered Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff M | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff I | Registered Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff N | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff O | Registered Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff Q | Registered Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff R | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff S | Registered Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff T | Registered Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff U | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff V | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff W | Registered Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff X | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff Y | Registered Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff Z | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff AA | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff BB | Licensed Practical Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff CC | Licensed Practical Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff DD | Registered Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff EE | Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff FF | Licensed Practical Nurse (agency) | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff GG | Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff HH | Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff II | Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
| Staff J | Registered Nurse | Documented medication administration notes related to Oxycodone-Acetaminophen |
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