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GOVERNOR BACON HEALTH CENTER

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GOVERNOR BACON HEALTH CENTER VS
All other Nursing Homes USA
General
City DELAWARE CITY   vs 0% Nursing Homes USA have DELAWARE CITY
State attribute explanation DE   vs 0.3% Nursing Homes USA have DE
Street P.O. BOX 559  
Zip Code 19706  
Phone 3028362550  
Overall Star Rating
(1.89 higher than average)
vs
3.11

Health Inspections Star Rating
(1.17 higher than average)
vs
2.83

Nurse Staffing Star Rating
(1.83 higher than average)
vs
3.17

Quality Measures Star Rating
(1.69 higher than average)
vs
3.31

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

Number of Certified Beds
94  (14.94 lower than average)
vs
108.94

Total Number of Residents
81  (10.25 lower than average)
vs
91.25

Percent of Occupied Beds
86 % (2.35 % higher than average)
vs
83.65 %

Health Survey Date 10/20/2011  
Fire Survey Date 10/20/2011  
Sprinkler Status Fully Sprinklered  vs 90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicaid  vs 3.5% Nursing Homes USA have Medicaid
Type of Ownership Government - State  vs 0.9% Nursing Homes USA have Government - State
Located Within a Hospital? No  vs 93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? No  vs 45.1% Nursing Homes USA don't 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? Yes  vs 31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  vs 99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
75.2  (17.04 higher than average)
vs
58.16

Total Enforcement Actions Count
75.2  (18.89 higher than average)
vs
56.31

# of deficiencies 12  
Percent of long-stay residents experiencing one or more falls with major injury 75.2 % 
Staff Information
Number of Residents
81  (10.38 lower than average)
vs
91.38

Number of RN Hours Per Resident Per Day
1.28  (0.51 higher than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
1.16  (0.32 higher than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
2.45  (0.86 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: 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: 03/22/2012
date Of Correction: 04/20/2012 

Deficiency #2 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 06/09/2010
date Of Correction: 09/03/2010 

Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 03/22/2012
date Of Correction: 04/20/2012 

Deficiency #2 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: 03/22/2012
date Of Correction: 04/20/2012 

Resident Assessment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 03/22/2012
date Of Correction: 04/20/2012 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional.
survey Date: 03/22/2012
date Of Correction: 04/20/2012 

Deficiency #3 Scope: Few
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: 06/09/2010
date Of Correction: 09/03/2010 

Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 03/22/2012
date Of Correction: 04/20/2012 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Choose A Doctor To Serve As The Medical Director To Create Resident Care Policies And Coordinate Medical Care In The Facility.
survey Date: 03/22/2012
date Of Correction: 04/20/2012 

Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: At Least Once A Month, Have A Licensed Pharmacist Review Each Resident's Medication(s) And Report Any Irregularities To The Attending Doctor.
survey Date: 06/09/2010
date Of Correction: 09/03/2010 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 06/09/2010
date Of Correction: 09/03/2010 

Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Prepare Food That Is Nutritional, Appetizing, Tasty, Attractive, Well-cooked, And At The Right Temperature.
survey Date: 06/09/2010
date Of Correction: 09/03/2010 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
44.6 % (19.51 % higher than average)
vs
25.09 %

Percent of long-stay residents who self-report moderate to severe pain
8.7 % (7.96 % lower than average)
vs
16.66 %

Percent of long-stay high-risk residents with pressure ulcers
5.3 % (7.28 % lower than average)
vs
12.58 %

Percent of long-stay residents who lose too much weight
1.3 % (10.53 % lower than average)
vs
11.83 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
75.2 % (59.57 % higher than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
75.2 % (61.74 % higher than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
4.3 % (24.08 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
1.3 % (42.38 % lower than average)
vs
43.68 %

Percent of long-stay residents experiencing one or more falls with major injury
75.2 % (59.68 % higher than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
45.6 % (20.21 % higher than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
75.2 % (51.5 % higher than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain 12.3:1 % 
Percent of long-stay high-risk residents with pressure ulcers
7.2 % (2.02 % lower than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
1.7 % (6.8 % lower than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
34.3 % (9.08 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
1 % (9.65 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
1.7 % (7.88 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
5.5 % (14.36 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
0.4 % (38.13 % lower than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
75.2 % (64.47 % higher than average)
vs
10.73 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
96.2 % (21.45 % higher than average)
vs
74.75 %



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