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LAKE SHORE VILLAGE HEALTHCARE CENTER

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LAKE SHORE VILLAGE HEALTHCARE CENTER VS
All other Nursing Homes USA
General
City WACO   vs 0.1% Nursing Homes USA have WACO
State attribute explanation TX   vs 7.6% Nursing Homes USA have TX
Street 2320 LAKE SHORE DR  
Zip Code 76708  
Phone 2547521075  
Overall Star Rating
(1.11 lower than average)
vs
3.11

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

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

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

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

Number of Certified Beds
151  (42.06 higher than average)
vs
108.94

Total Number of Residents
131  (39.75 higher than average)
vs
91.25

Percent of Occupied Beds
87 % (3.35 % higher than average)
vs
83.65 %

Health Survey Date 9/14/2011  
Fire Survey Date 9/15/2011  
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 - Partnership  vs 7.9% Nursing Homes USA have For profit - Partnership
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 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
(0.52 higher than average)
vs
7.48

Staff Information
Number of Residents
131  (39.62 higher than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.17  (0.6 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
1.09  (0.25 higher than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.26  (0.33 lower than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.05  (5.44 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.05  (0.05 lower than average)
vs
0.10

Environmental Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 01/13/2011
date Of Correction: 02/13/2011 

Mistreatment Deficiencies
Deficiency #1 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: 02/11/2010
date Of Correction: 03/11/2010 

Deficiency #2 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: 04/01/2009
date Of Correction: 05/01/2009 

Resident Rights Deficiencies
Deficiency #1 Scope: Few
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: 01/13/2011
date Of Correction: 02/13/2011 

Deficiency #2 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: 02/11/2010
date Of Correction: 03/11/2010 

Deficiency #3 Scope: Some
level Of Harm: 1
deficiency: Try To Resolve Each Resident's Complaints Quickly.
survey Date: 06/03/2009
date Of Correction: 07/03/2009 

Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.
survey Date: 06/27/2011
date Of Correction: 07/15/2011 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 01/13/2011
date Of Correction: 02/13/2011 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
22.8 % (2.29 % lower 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
4.5 % (12.16 % lower than average)
vs
16.66 %

Percent of long-stay high-risk residents with pressure ulcers
12.7 % (0.12 % higher than average)
vs
12.58 %

Percent of long-stay residents who lose too much weight
3.8 % (8.03 % lower than average)
vs
11.83 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
49.3 % (4.76 % higher than average)
vs
44.54 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
2.8 % (12.83 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
1.9 % (11.56 % lower than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
2.9 % (25.48 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
0.9 % (42.78 % lower than average)
vs
43.68 %

Percent of short-stay residents who self-report moderate to severe pain
20.9 % (4.12 % lower than average)
vs
25.02 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
85.9 % (1.26 % higher than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
84 % (0.06 % higher 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
1.9 % (13.62 % 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
75.2 % (51.5 % higher than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain
10.9 % (3.2 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
8.7 % (0.52 % lower than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
3.3 % (5.2 % lower than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
48 % (4.62 % higher than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.1 % (7.55 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
2.7 % (6.88 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
1.8 % (18.06 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
1.8 % (36.73 % lower than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
3.2 % (7.53 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
18.7 % (6.06 % lower than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
84.8 % (3.36 % higher than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
81.7 % (6.95 % higher than average)
vs
74.75 %

Percent of short-stay residents who newly received an antipsychotic medication 13.1:1 % 


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