Provider Name: DAMAS HOSPITAL SNF
Address: 2213 PONCE BY PASS, PONCE, PR 00717
Phone: (787) 840-8686
County: Ponce (560)
Ownership Type: Non profit - Corporation
Certified Beds: 25
Average Residents Per Day: 16.3 ()
Provider Type: Medicare, Resides in Hospital: No
Legal Business Name: HOSPITAL DAMAS INC
First Approved Date: September 8, 1988
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: None
Sprinkler System Status: Yes
Overall Rating: 4 ()
Health Inspection Rating: 3 ()
QM Rating: (2)
Long Stay QM Rating: (2)
Short Stay QM Rating: (2)
Staffing Rating: 5 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 0.00000, LPN Staff Hours Per Day: 0.2075, RN Staff Hours Per Day: 4.6934, Licensed Staff Hours Per Day: 4.9010
Total Nurse Staff Hours Per Day, per resident: 4.90100
Weekend Nurse Staff Hours: 3.93143, Weekend RN Staff Hours: 3.6564
PT Staff Hours Per Day, per resident: 1.5551
Nurse Staff Turnover: 30.0, Nurse Turnover Note:
RN Turnover: 27.8, RN Turnover Note:
Admin Left Number: , Admin Turnover Note: 6
Case Mix Nurse Aide Hours Per Day, per resident: 1.9319, Case Mix LPN Hours Per Day: 0.9299, Case Mix RN Hours Per Day: 0.5171
Adjusted Nurse Aide Hours Per Day, per resident: 0.00000, Adjusted LPN Hours Per Day: 0.1647, Adjusted RN Hours Per Day: 3.4195
Total Adjusted Nurse Hours Per Day, per resident: 4.57164
Adjusted Weekend Nurse Hours Per Day, per resident: 3.66723
Health Survey Dates and Scores: Cycle 1: 2023-04-13 (Score: 48), Cycle 2: 2022-04-28 (Score: 20), Cycle 3: 2021-07-22 (Score: 366)
Total Weighted Health Score: 91.667
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations: 5
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 75270.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 2213 PONCE BY PASS,PONCE,PR,00717 (18.0133, -66.614)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-19
Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-26
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-26
Type: Health, Deficiency: Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-26
Type: Health, Deficiency: Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-12
Type: Health, Deficiency: Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-06-05
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-29
Type: Health, Deficiency: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-05-05
Type: Health, Deficiency: Ensure a qualified health professional conducts resident assessments.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-05-03
Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2022-07-15
Type: Health, Deficiency: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-19
Type: Health, Deficiency: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-20
Type: Health, Deficiency: Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-19
Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-12
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: L - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-20
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-24
Type: Fire Safety, Tag: 0271, Version: New
Description: Have exits that are accessible at all times.
Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-24
Type: Fire Safety, Tag: 0291, Version: New
Description: Install emergency lighting that can last at least 1 1/2 hours.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-24
Type: Fire Safety, Tag: 0353, Version: New
Description: Inspect, test, and maintain automatic sprinkler systems.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-24
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-08-24
Type: Fire Safety, Tag: 0223, Version: New
Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-10-16
Type: Fire Safety, Tag: 0345, Version: New
Description: Have approved installation, maintenance and testing program for fire alarm systems.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-10-16
Type: Fire Safety, Tag: 0347, Version: New
Description: Properly provide smoke detection systems in areas open to corridors.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-10-16
Type: Fire Safety, Tag: 0355, Version: New
Description: Properly select, install, inspect, or maintain portable fire extinguishes.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-10-16
Type: Fire Safety, Tag: 0761, Version: New
Description: To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-10-16