Damas Hospital SNF
2213 Ponce By Pass, Ponce, PR 00717 · Non profit - Corporation · 25 certified beds · (787) 840-8686 Medicare only — no Medicaid
This home has serious findings on its record. Read them closely before you consider it.
- a strong health-inspection score (5/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- a high payroll-based staffing rating (5/5)
- lower-than-typical staff turnover (5% vs 45% nationally) — better care continuity
- fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
- it has abuse, neglect, or exploitation citations (F0600, F0606, F0609) — most recent Oct 2024
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0607) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- it has 1 actual-harm citation
- a high number of inspection citations overall (30) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
- the CMS record shows $10,839 in federal fines (most recent 2024-05-17)
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 5 of 5 |
| StaffingFrom payroll records (PBJ) | 5 of 5 |
| Quality measuresSelf-reported by the facility | Not rated |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | Not rated |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating improved from 4 to 5 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Short-stay residents who newly got an antipsychotic medication | 0.7% | 0.3% | 1.4% | worse than state‡ — see note marked double-dagger below the table |
| Short-stay residents given the seasonal flu vaccine | 99.5% | 97.9% | 79.4% | better |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
59.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 25 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Therapy staffing: this home’s payroll records show 1.73 therapist hours per resident per day in 2026Q1 — more than 99% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 59.1%CMS range 50.1–66.8 | 51.5% | Oct 2022–Sep 2024 | no different from U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.7%CMS range 6.4–19.4 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 45.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — Newly certified nursing home with less than 12-15 months of data available or the nursing home opened less than 6 months ago, and there were no data to submit or claims for this measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 95.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 5.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 25 beds and averages 18.8 residents a day — about 75% occupied, or roughly 6 beds typically open. It usually has some room. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.92 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 4.17 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 0.00 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.74 hrs/resident/day on weekends vs 5.40 on weekdays — 31% thinner on weekends — a notable drop. RN hours go from 4.65 to 2.98 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 5% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
30 citations, most serious first. The 11 most serious are shown; the remaining 19 are one tap away and print in full.
- Actual harm · G2024-05-17 · tag F0609 — failed to report abuse allegations — isolatedTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of incidents and complaints during Quality assurance and performance improvement (QAPI) program review and staff interview performed on 05/17/2024 at 11:20 AM, it was determined that the facility failed to ensure that all alleged violations involving neglect are reported to the State Survey Agency within 5 working days of the incident to verified appropriate corrective action is taken. Findings include: Facility policy Title: Abuse and Neglect last updated May 2023 was review on 05/17/2024 at 2:35 PM with QAPI officer (employee #8) Policy clearly stated on the procedures that any incidents/violations that been sustained after investigation that abuse or neglect occur must be reported to the state agency and to the required state nursing examination board agency. This policy did not include provisions who establish the time period when the violation were going to be reported. 1. While the Quality assurance and performance improvement (QAPI) program review was performed on 05/17/24 at 11:23 AM it…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2025-03-28 · tag F0805 — failed to prepare food in a form residents can eat — widespreadEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
What the surveyor found here — the official record, unedited, may be distressing
Based on dining observations, review of policies procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to ensure that each resident receives food that accommodates resident allergies, intolerances, and preferences. This deficiency was identified in 3 out of 21 residents of the sample selection receiving services (Residents #162, #163, #314). Findings include: 1. Resident # 314 does not take instant coffee, prefers to be prepared traditionally this was not provided. 2. Resident #162 referred to hot cereal was not palatable for her needs, she was provided with unsweetened hot cereal which she could not eat because of the flavor. 3. Resident #163 said the meat she was served was dry and was not palatable for her preference.
- Potential for harm · Fcited before2025-03-28 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the Kitchen, review of policies procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. Findings include: 1. During the visual inspection of the kitchen area it was observed that Chicken was held on temperature of 132 degrees Fahrenheit on serving container on line prep not reaching the required temp of 165 degrees Fahrenheit for poultry. 2. Meat freezer floor was observed uneven and with broken cement in entrance permitting mold and ice to develop. 3. Holding racks in meat freezer were observed with rust in tubing.
- Potential for harm · F2025-03-28 · tag F0813 — widespreadHave a policy regarding use and storage of foods brought to residents by family and other visitors.
What the surveyor found here — the official record, unedited, may be distressing
Based on review of policies, procedures and facility staff interview performed on 03/27/25, it was determined that the facility failed to comply with the policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. Findings include: During observation of the residents refrigerator a unlabeled yougurt and ice cream were found.
- Potential for harm · Fcited before2025-03-28 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment, review of policies procedures and facility staff interview performed on 03/27/2025 through 03/28/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed with the use of standards practice for prevention and requirements for temperature recording which could promote deterioration of the supply or the spread of microorganisms. This deficient practice could affect 21 out of 21 residents admitted receiving care at the facility. Findings include: The MDS Coordinator (employee #4) provided facility's policy and procedure last update on 02/2025 for Registro de Temperatura y Humedad en Almacenes de Suplidos de Materiales Médico Quirúrgicos. It was reviewed on 03/27/2025 at 1:45 PM. States that the air conditioning system temperature parameters, according to the standard, are 70°F to 75°F. In the procedure area. In section 2, it states that the physical plant will be notified if the temperature is not within the appropriate parameters and their…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-03-28 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the rooms, review of policies procedures and facility staff interview performed on 03/27/2025 from 8:00 AM through 3:00 PM, it was determined that the facility did not meet the requirements for sanitation of the air conditioner inlet grill compartment for 3 out of 3 residents' rooms. Findings include: The Supervisor (employee #2) provided facility's policy and procedure last update on 02/2025 for Reemplazo Filtros de Ductos de Aire Acondicionado. Replacement of Air Conditioning Duct Filters. Procedure: 2. The physical plant personnel will replace the air duct filters monthly. 6. The cleaning staff will clean the grill. 1. During the round provided in the rooms with the Physical Plant Manager employee #10 on 3/27/2025 from 8:00 AM to 3:00 PM, the following was observed: a. The air conditioning inlet grille compartments were observed to be dusty in rooms #309, #310, #311.
- Potential for harm · Ecited before2025-03-28 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment and facility staff interview performed on 03/27/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed to promote the resident right to receive service in a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. This deficient practice was observed on 8 out of 9 rooms at the facility visited. Findings include: 1. During the observations performed in the residents' rooms, with Physical Plant Director employee (#10) the following was observed: a) On 03/27/2025 from 9:00 AM through 9:40 AM it was observed the nightstands had parts of the plastic cover exposed in rooms #309, #311, #318 and #319. b) On 03/27/2025 from 9:10 AM through 9:40 AM it was observed the armchairs had armrest deteriorated in rooms #309, #311, #314 and #316. c) On 03/27/2025 at 9:40 AM it was observed the table tray is uneven in room [ROOM NUMBER]. d) On 03/27/2025 at 9:51 AM no cord was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-28 · tag F0636 — isolatedAssess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on the interview and records reviewed (RR), it was determined that the facility failed to complete the Comprehensive Minimum Data Set (MDS) assessment in a timely manner for one resident. This deficient practice was identified for 1 of 12 residents reviewed for MDS assessments. (Resident #513). Findings include: 1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she indicates that she has been using CPAP for a diagnosis of sleep apnea since 2018 and has always used the same machine. She indicates that her husband brought her the machine in a bag, but the nursing or medical staff were notified that she had that diagnosis and needed the machine to sleep. The resident refers that she took the CPAP out to use on the night of March 26, 2025, and realized that the machine was not working. 2. During the R.R. 513…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-28 · tag F0655 — isolatedCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of twelve medical records, resident interview and interview with the Respiratory Therapy Director (employee #1) performed from 03/27/2025 thru 03/28/2025, from 8:00 AM thru 4:00 PM, it was determined that the facility failed to develop and implement baseline care plan within 48 hours of a resident's admission in order to promote the continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services. This deficient practice was identified in 1 out of 12 records reviewed (RR). (RR #513) Findings include: 1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-03-28 · tag F0695 — failed to provide proper breathing / tracheostomy care — isolatedProvide safe and appropriate respiratory care for a resident when needed.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, twelve records reviewed (RR) and interviews with the Director of Respiratory Therapy (employee #1) and the Supervisor of Respiratory Therapy (employee #9), it was determined that facility failed to have the capability to provide needed respiratory care/services to residents with respiratory diagnosis that requires specialized respiratory care and/or services. This deficient practice affects 1 out of 14 sample cases (SC) receiving services. (SC#513) Findings include: 1. During initial pool on 03/27/2025 at 8:30 AM resident 513 is visited who is a female admitted on [DATE] for left artificial knee replacement and a Continuous Positive Airway Pressure (CPAP) machine is observed in the room. By interviewing the resident, she said that she has been using CPAP for a diagnosis of sleep apnea since 2018 and has always used the same machine. She indicates that her husband brought her the machine in a bag, but the nursing or medical staff were not notified that she had that diagnosis and needed the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2025-03-28 · tag F0925 — failed to control pests — isolatedMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment and facility staff interview performed on 03/27/2025 from 8:00 AM through 4:00 PM, it was determined that the facility failed maintain an effective pest control program so that the facility is free of pests. Findings include: 1. During the observations performed in the resident's rooms, with Physical Plant Director employee (#10) the following was observed: a) On 03/27/2025 at 9:15 AM spider was observed behind curtains in room [ROOM NUMBER].
Show the remaining 19 citations
- Potential for harm · F2024-10-30 · tag F0725 — failed to have enough nursing staff — widespreadProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview with the Director of nursing (employee #1) and Nursing supervisor (employee #2 )on 10/29/2024 through 10/30/2024 from 8:00 AM to 4:00 PM, it was determined that the facility failed to provide evidence that have and maintain sufficient nursing staff sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care. Findings include: 1.Director of Nursing (DON) was interviewed on 10/29/2024 at 1:00 PM and was asked by the surveyor for the categorization of residents admitted to the facility, the day alleged incidents of abuse and neglect occur on 10/20/2024. DON was asked in relation to the quantity of nursing personnel (License Practical Nurse- LPN's & Registered Nurse- RN's) assigned to be in charge of resident's care and distribution accordingly with residents categorization and needs. The DON stated during interview on 10/29/2024 at 1:30 PM that accordingly with resident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-30 · tag F0940 — failed to train staff — widespreadDevelop, implement, and/or maintain an effective training program for all new and existing staff members.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Credential files Reviewed (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect training and the Hand in Hand training was provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse. Findings include: During the review of SNF employee Abuse and neglected training and the Hand in Hand Training on 10/30/2024 at 1:00 pm, the following was found: 1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5 Preventing and Responding to Abuse. This nursing personnel took these two modules in 2023. The Hand-in- Hand -A training Series for Nursing Home was taken by…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-10-30 · tag F0942 — widespreadEnsure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
What the surveyor found here — the official record, unedited, may be distressing
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that Residents Right training is provided to all employees of the Skilled Nursing Facility (SNF). This deficient practice could affect all residents admitted at the facility. Findings include: 1. Review of 22 Credential file Review (CFR) on 10/30/2024 from 1:00 PM through at 2:00 PM it was found that 22 nursing personnel working in the SNF did not have the Residents Rights training. 2. The Facility failed to ensure to provide all employees of the SNF with the Residents Right, training to ensure that the employees are knowledgeable to react and respond appropriately to protect the residents' rights.
- Potential for harm · F2024-10-30 · tag F0943 — widespreadGive their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure an effective training program for all staff that includes, abuse, neglect, exploitation, misappropriation of residents property, dementia management, Residents Right and the Hand in Hand at minimum. This deficient practice was identified in 22 out of 22 credential files reviewed to investigate compliance with training requirements. (CFR #1 through #22). Findings include: During the review of SNF employee training on 10/30/2024 from 1:00 PM through 2:00 PM, the following was found: 1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM, it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. 4 out of 22 (22.7%) of nursing personnel working in the SNF did not complete Pain Management. 4 out of 22 (18.2%) of nursing personnel working in the SNF did not complete Resident experience. 2. The facility failed to provide all employees of the SNF with…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0600 — failed to protect residents from abuse and neglect — isolatedProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect and the Hand in Hand trainings were provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse. This deficient practice was identified in 7 out of 22 credential files reviewed to investigated compliance with training requirements. ( CF # 11,#12,#13,#14,#15, #16, and #17). Findings include: During the review of SNF employee Abuse and neglected and the Hand in Hand Trainings on 10/30/2024 from 1:00 PM till 2:00 PM, 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. 1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0606 — failed to not employ staff found guilty of abuse — isolatedNot hire anyone with a finding of abuse, neglect, exploitation, or theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of facility Self-Reported incident, interviews with facility nursing supervisor and human resource officials and review of policies and procedures performed on 10/30/2024 at 11:00 AM, it was determined that the facility failed to maintain an exhaustive screening process before an employee is assigned to provide direct care to residents and form part of the facility direct care personnel. This deficient practice was identified in 2 out of 7 complaints investigated with potential abuse and neglect incidents. Findings include: Review of the facility's policy Title Abuse and Neglect effective in May 2023, policy clearly stated that it is the responsibility of the facility to screen all potential employees in relation to abuse and neglect. Policy includes provisions to be followed to ensure that diligent process must be implemented to assure history of the potential employee behavior on previous work scenario is considered before is sent to the area from which is being considered. 1. The facility report to the Puerto Rico State Agency(PRSA) Medicare Division an incident…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-10-30 · tag F0607 — failed to have anti-abuse policies — isolatedDevelop and implement policies and procedures to prevent abuse, neglect, and theft.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on Credential file Review (CFR) and interviews with the Associate Director of Nurse (DON) employee #1, it was determined that the facility failed to ensure that the abuse and neglect training and the Hand in Hand training was provided to all employees of the Skilled Nursing Facility (SNF) and ensure employees are knowledgeable to react and respond appropriately to protect the resident's right to be free from mental abuse. Findings include: During the review of SNF employee Abuse and neglected training and the Hand in Hand Training on 10/30/2024 at 1:00 pm, the following was found: 1.Review of 22 Credential file Review (CFR) on 10/30/2024 at 2:00 PM it was found that 7 out of 22 (31.8%) of nursing personnel working in the SNF did not complete the hand in hand training. These employees took modules 1, module 2 and module 3; they did not complete module 4 Being with a person with Dementia: Making a Difference and module 5 Preventing and Responding to Abuse. This nursing personnel took these two modules in 2023. The Hand-in- Hand -A training Series for Nursing Home was taken by an…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-05-17 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to distribute and serve food in accordance with facility established infection control precautions. This deficiency affects 19 out of 19 cases reviewed during dining observations. Findings include: 1. During dining observations procedures performed on 05/16/24 at 12:00 PM it was identified that kitchen personnel (employee #4) brought the lunch trays in a food warmer cart. 2. Kitchen personnel (employee #5) did not check if resident was in the room before taking out the lunch tray from the food warmer cart. He took off the trays of room [ROOM NUMBER]-2, 308-2 309-2 and 311-1before checking if those residents were in the room. Since residents were not in their room, he returns the lunch tray again to the food warmer. 3. Kitchen personnel return lunch trays to the food warmer cart that had been in the environment of resident's rooms and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · F2024-05-17 · tag F0868 — widespreadHave the Quality Assessment and Assurance group have the required members and meet at least quarterly
What the surveyor found here — an excerpt from the official record, may be distressing
Based on review of Quality Assessment Performance Improvement (QAPI) activities performed on 05/16/24 through 05/17/24 from 8:00 AM till 5:00 PM and interview with the facility QAPI (employee #8) it was determined that facility failed to ensure the participation of all required members on the QAPI committee meetings. Findings include: 1. During review of facility QAPI committee meetings during year 2023 and the months of February 2024 and April 2024 the following was identified: Upon review of facility attendance list related to QAPI program committee meeting activities it was identified that the Infection Preventionist did not participate in every QAPI committee meeting. a. There is no evidence of participation of facility Infection Preventionist on QAPI committee meetings performed on May 25, 2023, September 14, 2023, October 26, 2023, February 15, 2024, and April 15, 2024. b. During interview on 05/17/24 at 1:30 PM facility QAPI (employee #8) stated that infection control officer gave her the infection control report and discusses with her relevant areas and is her as the QAPI,…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-05-17 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on infection control observation, and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:30 PM, it was determined that the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Findings include: During the medication Pass performed on 5/17/2024 from 8:30 AM till 9:35 AM it was the following: 1. During the medication pass with the registered nurse employee #6 it was observed that nurse did not wash her hand before putting on the non-sterile glove in 4 out of 4 opportunity to wash her hand before gloving hands. 2. During the employee #6 was serving the medication, a piece of paper from the surveyor fell on the floor and the nurse picked it up from the floor and gave it to the surveyor. She continued serving the medication without washing her hands. 3. During the process that the employee #6…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2024-05-17 · tag F0921 — failed to keep a safe, functional, sanitary building — widespreadMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
What the surveyor found here — the official record, unedited, may be distressing
Based on observations of the physical environment and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to ensure residents to reside and receive services in the facility with reasonable accommodation. Findings include: During observational tour with Engineering Director (employee #10) the following was found: 1. 3 out of 15 wheelchairs were found with loose brake frame 1out of 2 four contact points walking canes with paper creating pressure on suctions cup. 2 of 2 chairs in occupational therapy found with rust. 2. Plastic box used to store linen was observed directly on the floor of the clean linen room 3. Biomedical waste room was observed with the door open and garbage overflowing from the container 4. Two cardboard boxes containing medical equipment (masks and lines) were observed directly on the floor of the respiratory therapy room.
- Potential for harm · E2024-05-17 · tag F0558 — failed to accommodate residents' needs and preferences — patternReasonably accommodate the needs and preferences of each resident.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to ensure residents to reside and receive services in the facility with reasonable accommodation of residents. Findings include: During observational tour the following was observed related with environment in the facility: 1. During the evaluation of room [ROOM NUMBER], it was observed that the clinical staff was transferring the resident of 307A bed from the wheelchair to the bed using the crane. It was observed that the clinical staff invaded the space of the other resident with wheelchair and crane. Resident of #307 B expressed discomfort during the process.
- Potential for harm · Ecited before2024-05-17 · tag F0584 — failed to keep a safe, clean, comfortable home — patternHonor 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.
What the surveyor found here — the official record, unedited, may be distressing
Based on Physical Environment observation, and facility staff interview performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 4:00 PM, it was determined that the facility failed to maintain safe, clean, comfortable, and homelike environment. Findings include: 1. During visual observation and patient interview on physical environment of the facility bathroom it was observed that lightning fixture mounted on the wall did not provide adequate illumination in the shower area. The light fixture location is lower than the shower curtain which does not permit full light difumination on this area. 2. During visual observation of residents sleeping areas it was noticed that bed platforms behind head rest had accumulation of dust particles.
- Potential for harm · Ecited before2024-05-17 · tag F0925 — failed to control pests — patternMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations of the physical environment performed on 05/16/2024 through 05/17/2024 from 8:00 AM through 5:00 PM, it was determined that the facility failed maintain an effective pest control program so that the facility is free of pests. Findings include: 1. Spiders, spider webs and ants were observed behind curtains in rooms #309, #310, #311, #317 and #319. 2. Particulate, apparent soil was observed in the corner of room [ROOM NUMBER] indicative of an anthill starting to form.
- Potential for harm · D2024-05-17 · tag F0550 — failed to protect resident dignity and rights — isolatedHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations, and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to provide services in a manner that respect, and dignity of residents was maintained. This deficiency was identified in 1 out of 19 cases reviewed during initial pool process (Resident #9). Findings include: 1. Resident #9 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Fracture of Left Femur. During the record review performed on 5/16/2024 at 10:12 AM it was found that resident was presenting periods of disorientation and had urine incontinence. 2. On 05/16/2024 at 12:00 PM resident was observed located in the recreative room seating on a wheelchair were other resident and she receive their lunch trays. When resident #9 is observed eating lunch she was constantly touching her back area and pulling a blue medical surgical pad that personnel put in the seat of the wheelchair. After she touches her back…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-17 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — the official record, unedited, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to promote the right to personal privacy and confidentiality for all aspects of care and services. This deficiency was identified in 1 out of 19 cases reviewed during initial pool process (Resident located on room [ROOM NUMBER]-1). Findings include: 1. Nursing personnel (employee #7) proceed to perform the Dextrostix test to residents located on room [ROOM NUMBER]-1. Before proceeding to puncture resident finger with the lancet, nurse pulled the privacy curtain to provide privacy to resident, however the curtain did not slide completely in a way that covers resident bed area. No matter what the curtain did not slide completely in a way that covers resident area, the nurse proceeds to perform the blood glucose test. In bed 309-2 it was observed relatives with the resident located in this bed that could see procedure perform to resident located on bed 309-1.
- Potential for harm · D2024-05-17 · tag F0676 — failed to keep up residents' daily-living abilities — isolatedEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on a recertification survey and dining observations, performed on 05/16/2024 through 05/18/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This deficiency was identified in 1 out of 19 cases reviewed during initial pool process (Resident #9). Findings include: 1. Resident #9 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Fracture of Left Femur. During the record review performed on 5/16/2024 at 10:12 AM it was found that resident was presenting periods of disorientation and had urine incontinence. 2. On 05/16/2024 at 12:00 PM resident was observed located in the recreative room seating on a wheelchair where other residents and she receive their lunch trays. Resident #9 is observed eating lunch without…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-17 · tag F0677 — failed to help fully-dependent residents with daily care — isolatedProvide care and assistance to perform activities of daily living for any resident who is unable.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on dining observations and record reviewed (RR) performed on 05/16/2024 through 05/18/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to provide the necessary care and services to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming, and personal care. This deficiency was identified in 1 out of 19 cases reviewed during initial pool process (Resident #9). Findings include: 1. Resident #9 is a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of Fracture of Left Femur. During the R.R. performed on 5/16/2024 at 10:12 AM it was found that resident was presenting periods of disorientation and had urine incontinence. 2. On 05/16/2024 at 12:00 PM resident was observed located in the recreative room seating on a wheelchair where other residents and she receive their lunch trays. When resident #9 is observed eating lunch she was constantly touching her back area and pulling a blue…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-05-17 · tag F0803 — failed to meet residents' dietary needs — isolatedEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on dining observations, review of policies procedures and facility staff interview performed on 05/16/2024 through 05/17/2024 to from 8:30 AM through 4:30 PM, it was determined that the facility failed to ensure that input received from residents and preferences related with food services are met. This deficiency affects 1 out of 19 cases reviewed during dining observations (Resident #77). Findings include: 1. During dining observations on 05/16/24 at 12:00 PM it was observed that chicken asopao is the main dish in the lunch. It was observed that resident #77 made a bad face when she received the lunch tray. 2. Resident #77 was asked on 05/16/24 at 12:10 PM if she likes chicken asopao. She explains to the surveyor that she like soups and asopao but not as main dish because she is a big woman, she likes to eat and when she eats soup or asopao she gets hungry quickly. 3. Surveyor ask resident #77 on 05/16/24 at 12:15 PM if she wants a substitution in her lunch dinner tray. Resident stated that she wants the substitution and asked if facility had an alternate menu. Surveyor…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
$10,839 in federal fines across 1 penalty.
- $10,839 — penalty dated 2024-05-17
Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.
Who owns this facility
| Owner / manager | Type | Role | Since |
|---|---|---|---|
| MAGRANER SUAREZ, MIGUEL | Individual | CORPORATE DIRECTOR; ADP OF THE SNF | since 10/01/2024 |
| TORRES-BERNAL, MARIA | Individual | CORPORATE DIRECTOR; CORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROL; ADP OF THE SNF | since 01/01/2013 |
CMS files one row per role, so the 6 rows in the source record cover these 2 parties — each is shown once here with every role it holds. Nothing is omitted. The source lists no ownership percentage for any of them — PECOS records a share only for equity interests, not for board or management roles.
What families pay in PR
CMS lists this home as Medicare-certified only — it is not Medicaid-certified, so it generally cannot accept Medicaid as payment for a long-term stay. That makes it one of roughly 545 homes nationally where a Medicaid-funded placement is not an option. If you expect to rely on Medicaid, ask the home directly before you tour, and see the Puerto Rico Medicaid page for homes that do.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner. The starred figure is the national median (no state figure published).
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 405023. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-03-05, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.