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DECATUR NURSING AND REHABILITATION LP

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DECATUR NURSING AND REHABILITATION LP VS
All other Nursing Homes USA
General
City DECATUR   vs 0.2% Nursing Homes USA have DECATUR
State attribute explanation TX   vs 7.6% Nursing Homes USA have TX
Street 605 W MULBERRY  
Zip Code 76234  
Phone 9406275444  
Overall Star Rating
(2.11 lower than average)
vs
3.11

Health Inspections Star Rating
(1.83 lower than average)
vs
2.83

Nurse Staffing Star Rating
(0.17 lower than average)
vs
3.17

Quality Measures Star Rating
(2.31 lower than average)
vs
3.31

RN Only Star Rating
(0.83 higher than average)
vs
3.17

Number of Certified Beds
58  (50.94 lower than average)
vs
108.94

Total Number of Residents
33  (58.25 lower than average)
vs
91.25

Percent of Occupied Beds
57 % (26.65 % lower than average)
vs
83.65 %

Health Survey Date 12/20/2011  
Fire Survey Date 11/30/2011  
Sprinkler Status Fully Sprinklered  vs 90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  vs 91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  vs 56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  vs 93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  vs 54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   vs 66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  vs 90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? No  vs 68.7% Nursing Homes USA don't have Quality Indicator Survey?
Special Focus Facility? Yes  vs 1% Nursing Homes USA have Special Focus Facility?
Civil Money Penalty Count
(52.16 lower than average)
vs
58.16

Total Enforcement Actions Count
(50.31 lower than average)
vs
56.31

# of deficiencies
(1.52 higher than average)
vs
7.48

Staff Information
Number of Residents
26  (65.38 lower than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.89  (0.12 higher than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
1.07  (0.23 higher than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.96  (0.37 higher than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.02  (5.47 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.02  (0.08 lower than average)
vs
0.10

Environmental Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 4
deficiency: Make Sure There Is A Pest Control Program To Prevent/deal With Mice, Insects, Or Other Pests.
survey Date: 06/13/2011
date Of Correction: 07/15/2011 

Deficiency #2 Scope: Many
level Of Harm: 4
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 06/13/2011
date Of Correction: 07/15/2011 

Deficiency #3 Scope: Some
level Of Harm: 1
deficiency: Keep All Essential Equipment Working Safely.
survey Date: 08/20/2010
date Of Correction: 09/17/2010 

Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 3
deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.
survey Date: 03/11/2011
date Of Correction: 04/08/2011 

Deficiency #2 Scope: Many
level Of Harm: 4
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 09/20/2010
date Of Correction: 09/21/2010 

Deficiency #3 Scope: Many
level Of Harm: 4
deficiency: 1) Hire Only People With No Legal History Of Abusing, Neglecting Or Mistreating Residents; Or 2) Report And Investigate Any Acts Or Reports Of Abuse, Neglect Or Mistreatment Of Residents.
survey Date: 09/20/2010
date Of Correction: 09/21/2010 

Deficiency #4 Scope: Many
level Of Harm: 4
deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.
survey Date: 09/20/2010
date Of Correction: 09/21/2010 

Quality Care Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 4
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 06/13/2011
date Of Correction: 07/15/2011 

Administration Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 4
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 09/20/2010
date Of Correction: 09/21/2010 

Quality Measures Q1
Percent of short-stay residents who newly received an antipsychotic medication
75.2  (29.3 higher than average)
vs
45.90

Quality Measures Q3
Deficiency #1 25.7 % 
Percent of long-stay residents who received an antipsychotic medication
46.2 % (20.81 % higher than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
5.1 % (18.6 % lower than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain
26.4 % (12.3 % higher than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers 9.4 / 10.4 % 
Percent of long-stay residents who lose too much weight
6.3 % (2.2 % lower than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
13.3 % (30.08 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
1.3 % (9.35 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection 14.7:1 % 
Percent of long-stay residents who have depressive symptoms
6.3 % (13.56 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
1 % (37.53 % lower than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
7.3 % (3.43 % lower than average)
vs
10.73 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
75 % (6.44 % lower than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
73.3 % (1.45 % lower than average)
vs
74.75 %



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