EL PASO HEALTH & REHABILITATION CENTER

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General
City	EL PASO	vs	0.1% Nursing Homes USA have EL PASO
State attribute explanation	TX	vs	7.6% Nursing Homes USA have TX	compare TX Nursing Homes USA
Street	11525 VISTA DEL SOL DR
Zip Code	79936
Phone	9158553636
Overall Star Rating	1 (2.11 lower than average)	vs	3.11	Compare similar Overall Star Rating (1)
Health Inspections Star Rating	1 (1.83 lower than average)	vs	2.83	Compare similar Health Inspections Star Rating (1)
Nurse Staffing Star Rating	2 (1.17 lower than average)	vs	3.17	Compare similar Nurse Staffing Star Rating (2)
Quality Measures Star Rating	4 (0.69 higher than average)	vs	3.31	Compare similar Quality Measures Star Rating (4)
RN Only Star Rating	1 (2.17 lower than average)	vs	3.17	Compare similar RN Only Star Rating (1)
Number of Certified Beds	146 (37.06 higher than average)	vs	108.94	Compare similar Number of Certified Beds (146)
Total Number of Residents	137 (45.75 higher than average)	vs	91.25	Compare similar Total Number of Residents (137)
Percent of Occupied Beds	94 % (10.35 % higher than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (94) %
Health Survey Date	2/17/2012
Fire Survey Date	2/15/2012
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	compare Medicare and Medicaid Nursing Homes USA
Type of Ownership	For Profit - Corporation	vs	56.7% Nursing Homes USA have For profit - Corporation	compare For profit - Corporation Nursing Homes USA
Located Within a Hospital?	No	vs	93.6% Nursing Homes USA don't have Located Within a Hospital?	Compare similar 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?	No	vs	99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count	4 (54.16 lower than average)	vs	58.16
Total Enforcement Actions Count	4 (52.31 lower than average)	vs	56.31
# of deficiencies	35 (27.52 higher than average)	vs	7.48

Staff Information
Number of Residents	137 (45.62 higher than average)	vs	91.38
Number of RN Hours Per Resident Per Day	0.3 (0.47 lower than average)	vs	0.77
Number of LPN/LVN Hours Per Resident Per Day	1.32 (0.48 higher than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	1.63 (0.04 higher than average)	vs	1.59
Number of CNA Hours Per Resident Per Day	0.08 (5.41 lower than average)	vs	5.49
Number Therapy Hours Per Resident Per Day	0.08 (0.02 lower than average)	vs	0.10

Environmental Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Provide Housekeeping And Maintenance Services. survey Date: 02/17/2012 date Of Correction: 03/16/2012
Deficiency #2		Scope: Some level Of Harm: 4 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 10/21/2011 date Of Correction: 10/21/2011
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 06/24/2011 date Of Correction: 07/30/2011
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 01/14/2010 date Of Correction: 02/11/2010
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Provide Housekeeping And Maintenance Services. survey Date: 05/22/2009 date Of Correction: 07/10/2009

Mistreatment Deficiencies
Deficiency #1		Scope: Some level Of Harm: 4 deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment. survey Date: 10/21/2011 date Of Correction: 10/21/2011
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 06/24/2011 date Of Correction: 07/30/2011
Deficiency #3		Scope: Few level Of Harm: 2 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: 06/24/2011 date Of Correction: 07/30/2011
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 04/01/2011 date Of Correction: 04/30/2011
Deficiency #5		Scope: Few level Of Harm: 2 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: 04/01/2011 date Of Correction: 04/30/2011
Deficiency #6		Scope: Some level Of Harm: 2 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: 03/04/2011 date Of Correction: 04/15/2011
Deficiency #7		Scope: Some level Of Harm: 2 deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment. survey Date: 03/04/2011 date Of Correction: 04/15/2011
Deficiency #8		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 07/31/2009 date Of Correction: 08/15/2009
Deficiency #9		Scope: Some level Of Harm: 2 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: 07/31/2009 date Of Correction: 08/15/2009

Resident Rights Deficiencies
Deficiency #1		Scope: Some level Of Harm: 3 deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident. survey Date: 04/01/2011 date Of Correction: 04/30/2011
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality. survey Date: 03/04/2011 date Of Correction: 04/15/2011
Deficiency #3		Scope: Few level Of Harm: 2 deficiency: Try To Resolve Each Resident's Complaints Quickly. survey Date: 03/04/2011 date Of Correction: 04/15/2011
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident. survey Date: 01/14/2010 date Of Correction: 02/11/2010
Deficiency #5		Scope: Few level Of Harm: 2 deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident. survey Date: 08/13/2009 date Of Correction: 09/02/2009
Deficiency #6		Scope: Few level Of Harm: 3 deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident. survey Date: 06/11/2009 date Of Correction: 07/17/2009

Quality Care Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 08/15/2011 date Of Correction: 09/02/2011
Deficiency #2		Scope: Some level Of Harm: 3 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 04/01/2011 date Of Correction: 04/30/2011
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 02/04/2011 date Of Correction: 02/28/2011
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life. survey Date: 03/26/2010 date Of Correction: 04/30/2010
Deficiency #5		Scope: Few level Of Harm: 3 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 06/11/2009 date Of Correction: 07/17/2009

Resident Assessment Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured. survey Date: 01/14/2010 date Of Correction: 02/11/2010

Administration Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards. survey Date: 10/21/2011 date Of Correction: 11/11/2011
Deficiency #2		Scope: Some level Of Harm: 4 deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident . survey Date: 10/21/2011 date Of Correction: 10/21/2011
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards. survey Date: 04/01/2011 date Of Correction: 04/30/2011

Pharmacy Service Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 02/17/2012 date Of Correction: 03/08/2012
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards. survey Date: 09/16/2010 date Of Correction: 10/08/2010
Deficiency #3		Scope: Few level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 06/18/2010 date Of Correction: 07/11/2010
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 05/18/2010 date Of Correction: 06/19/2010
Deficiency #5		Scope: Few level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 08/13/2009 date Of Correction: 09/02/2009
Deficiency #6		Scope: Some level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 05/22/2009 date Of Correction: 07/10/2009

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication	20 % (5.09 % lower than average)	vs	25.09 %
Percent of long-stay residents whose need for help with daily activities has increased	0.7 % (32.25 % lower than average)	vs	32.95 %
Percent of long-stay residents who self-report moderate to severe pain	2.3 % (14.36 % lower than average)	vs	16.66 %
Percent of long-stay high-risk residents with pressure ulcers	75.2 % (62.62 % higher than average)	vs	12.58 %
Percent of long-stay residents who lose too much weight	5.4 % (6.43 % lower than average)	vs	11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	67.3 % (22.76 % higher than average)	vs	44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	0.9 % (14.73 % lower than average)	vs	15.63 %
Percent of long-stay residents with a urinary tract infection	0.9 % (12.56 % lower than average)	vs	13.46 %
Percent of long-stay residents who have depressive symptoms	10.6 % (17.78 % lower than average)	vs	28.38 %
Percent of long-stay residents who were physically restrained	3.7 % (39.98 % lower than average)	vs	43.68 %
Percent of short-stay residents who self-report moderate to severe pain	8.3 % (16.72 % lower than average)	vs	25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	3.7 % (80.94 % lower than average)	vs	84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	75.2 % (8.74 % lower than average)	vs	83.94 %
Percent of short-stay residents who newly received an antipsychotic medication	75.2 (29.3 higher than average)	vs	45.90
Percent of long-stay residents experiencing one or more falls with major injury	1.7 % (13.82 % lower than average)	vs	15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication	21.8 % (3.59 % lower than average)	vs	25.39 %
Percent of long-stay residents whose need for help with daily activities has increased	0.9 % (22.8 % lower than average)	vs	23.70 %
Percent of long-stay residents who self-report moderate to severe pain	5.1 % (9 % lower than average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	2.4 % (6.82 % lower than average)	vs	9.22 %
Percent of long-stay residents who lose too much weight	4.8 % (3.7 % lower than average)	vs	8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	68.1 % (24.72 % higher than average)	vs	43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	1.4 % (9.25 % lower than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	1.4 % (8.18 % lower than average)	vs	9.58 %
Percent of long-stay residents who have depressive symptoms	11.6:1 %
Percent of long-stay residents who were physically restrained	7.1 % (31.43 % lower than average)	vs	38.53 %
Percent of long-stay residents experiencing one or more falls with major injury	3.1 % (7.63 % lower than average)	vs	10.73 %
Percent of short-stay residents who self-report moderate to severe pain	18.3 % (6.46 % lower than average)	vs	24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	6.4 % (75.04 % lower than average)	vs	81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	2.20 % (72.55 % lower than average)	vs	74.75 %
Percent of short-stay residents who newly received an antipsychotic medication	7.9:1 %