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HAYS NURSING & REHAB CENTER

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HAYS NURSING & REHAB CENTER VS
All other Nursing Homes USA
General
City SAN MARCOS   vs 0% Nursing Homes USA have SAN MARCOS
State attribute explanation TX   vs 7.6% Nursing Homes USA have TX
Street 1900 MEDICAL PKWY  
Zip Code 78666  
Phone 5123961888  
Overall Star Rating
(1.11 lower than average)
vs
3.11

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

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

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

RN Only Star Rating
(0.17 lower than average)
vs
3.17

Number of Certified Beds
116  (7.06 higher than average)
vs
108.94

Total Number of Residents
90  (1.25 lower than average)
vs
91.25

Percent of Occupied Beds
78 % (5.65 % lower than average)
vs
83.65 %

Health Survey Date 11/4/2011  
Fire Survey Date 11/3/2011  
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 Non Profit - Corporation  vs 18.7% Nursing Homes USA have Non profit - Corporation
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 Both  vs 29.8% Nursing Homes USA have Both
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
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
10  (2.52 higher than average)
vs
7.48

Staff Information
Number of Residents
90  (1.38 lower than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.56  (0.21 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.54  (0.3 lower than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.1  (0.49 lower than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.07  (5.42 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.07  (0.03 lower than average)
vs
0.10

Environmental Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Provide At Least One Room Set Aside To Use As A Resident Dining Room And For Activities, That Is A Good Size, With Good Lighting, Air Flow And Furniture.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

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: 07/23/2009
date Of Correction: 08/23/2009 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Provide Housekeeping And Maintenance Services.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

Mistreatment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

Resident Rights Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 1
deficiency: Provide Access To A Telephone For Resident To Use In Private.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Make Sure That Nurse Aides Show They Have The Skills And Techniques To Be Able To Care For Residents' Needs.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: 1) Review The Work Of Each Nurse Aide Every Year; And 2) Give Regular In-service Training Based Upon These Reviews.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

Pharmacy Service Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: 1) Provide 3 Meals At Regular Times; 2) Serve Breakfast Within 14 Hours After Dinner; Or 3) Offer A Snack At Bedtime Each Day.
survey Date: 07/23/2009
date Of Correction: 08/23/2009 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
32.1 % (7.01 % higher than average)
vs
25.09 %

Percent of long-stay residents whose need for help with daily activities has increased
75.2 % (42.25 % higher than average)
vs
32.95 %

Percent of long-stay residents who self-report moderate to severe pain 10.7:1 % 
Percent of long-stay high-risk residents with pressure ulcers
20.8 % (8.22 % higher than average)
vs
12.58 %

Percent of long-stay residents who lose too much weight
6.3 % (5.53 % lower than average)
vs
11.83 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
63.6 % (19.06 % higher than average)
vs
44.54 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
2.20 % (13.43 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
7.5 % (5.96 % lower than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
3.6 % (24.78 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
1.2 % (42.48 % lower than average)
vs
43.68 %

Percent of short-stay residents who self-report moderate to severe pain
22.7 (72.9) % (2.32 % lower than average)
vs
25.02 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
62.2 % (22.44 % lower than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
34.7 % (49.24 % 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
75.2 % (59.68 % higher than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
31.8 % (6.41 % 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
8.7 % (5.4 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
10.5 % (1.28 % higher than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
13.4 % (4.9 % higher than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
61.9 % (18.52 % higher than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.7 % (6.95 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection 10.1:1 % 
Percent of long-stay residents who have depressive symptoms
3.2 % (16.66 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
1.2 % (37.33 % lower than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
0.4 % (10.33 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
27.1 % (2.34 % higher than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
73.7 % (7.74 % lower than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
62.9 % (11.85 % lower than average)
vs
74.75 %

Percent of short-stay residents who newly received an antipsychotic medication
6.3 % (11.04 % lower than average)
vs
17.34 %



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