LEGACY NURSING AND REHABILITATION CENTER

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General
City	MARTINEZ	vs	0% Nursing Homes USA have MARTINEZ
State attribute explanation	CA	vs	7.8% Nursing Homes USA have CA
Street	1790 MUIR ROAD
Zip Code	94553
Phone	9252288383
Overall Star Rating	3 (0.11 lower than average)	vs	3.11	Compare similar Overall Star Rating (3)
Health Inspections Star Rating	2 (0.83 lower than average)	vs	2.83	Compare similar Health Inspections Star Rating (2)
Nurse Staffing Star Rating	4 (0.83 higher than average)	vs	3.17	Compare similar Nurse Staffing Star Rating (4)
Quality Measures Star Rating	2 (1.31 lower than average)	vs	3.31	Compare similar Quality Measures Star Rating (2)
RN Only Star Rating	2 (1.17 lower than average)	vs	3.17	Compare similar RN Only Star Rating (2)
Number of Certified Beds	96 (12.94 lower than average)	vs	108.94	Compare similar Number of Certified Beds (96)
Total Number of Residents	94 (2.75 higher than average)	vs	91.25	Compare similar Total Number of Residents (94)
Percent of Occupied Beds	98 % (14.35 % higher than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (98) %
Health Survey Date	3/15/2012
Fire Survey Date	3/21/2012
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?	No	vs	45.1% Nursing Homes USA don't have Multi Nursing Home Ownership?
Resident and Family Councils	None	vs	3.9% Nursing Homes USA have None
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	19 (11.52 higher than average)	vs	7.48

Staff Information
Number of Residents	94 (2.62 higher than average)	vs	91.38
Number of RN Hours Per Resident Per Day	0.43 (0.34 lower than average)	vs	0.77
Number of LPN/LVN Hours Per Resident Per Day	2.04 (1.2 higher than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	2.48 (0.89 higher than average)	vs	1.59
Number of CNA Hours Per Resident Per Day	0.11 (5.38 lower than average)	vs	5.49
Number Therapy Hours Per Resident Per Day	0.11 (0.01 higher than average)	vs	0.10

Environmental Deficiencies
Deficiency #1		Scope: Few 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: 10/10/2011 date Of Correction: 10/27/2011
Deficiency #2		Scope: Few 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: 09/03/2010 date Of Correction: 10/29/2010
Deficiency #3		Scope: Few 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: 06/03/2010 date Of Correction: Not Available
Deficiency #4		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: 06/19/2009 date Of Correction: 07/02/2009

Mistreatment Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others. survey Date: 05/14/2012 date Of Correction: 06/06/2012
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: 12/20/2010 date Of Correction: 01/20/2011
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: 11/24/2010 date Of Correction: 02/08/2011
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment. survey Date: 11/24/2010 date Of Correction: 02/08/2011

Resident Rights Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Help And Prepare Each Resident For A Safe And Easy Discharge And Transfer From The Nursing Home. survey Date: 08/17/2010 date Of Correction: 11/04/2010
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Provide Enough Notice Before Discharging Or Transferring A Resident. survey Date: 08/17/2010 date Of Correction: 11/04/2010
Deficiency #3		Scope: Few level Of Harm: 2 deficiency: Establish And Follow A Written Policy That Permits A Resident To Return To The Nursing Home After Hospitalization. survey Date: 08/10/2010 date Of Correction: 10/14/2010
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Tell The Resident Or The Resident's Representative In Writing How Long The Nursing Home Will Hold The Resident's Bed. survey Date: 08/10/2010 date Of Correction: 10/14/2010
Deficiency #5		Scope: Few level Of Harm: 2 deficiency: Provide Enough Notice Before Discharging Or Transferring A Resident. survey Date: 08/10/2010 date Of Correction: 10/14/2010
Deficiency #6		Scope: Few level Of Harm: 2 deficiency: Notify The Resident Or Provide Reasons For A Transfer Or Discharge. survey Date: 08/10/2010 date Of Correction: 10/14/2010

Resident Assessment Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Develop A Post-discharge Plan With The Resident And Family For The Resident's Care After Leaving The Nursing Home. survey Date: 08/17/2010 date Of Correction: 11/04/2010
Deficiency #2		Scope: Some level Of Harm: 1 deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured. survey Date: 01/07/2010 date Of Correction: 03/31/2010

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: 10/01/2009 date Of Correction: 11/01/2009

Pharmacy Service Deficiencies
Deficiency #1		Scope: Some level Of Harm: 1 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: 01/07/2010 date Of Correction: 03/31/2010
Deficiency #2		Scope: Some level Of Harm: 1 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: 01/07/2010 date Of Correction: 03/31/2010

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication	38 % (12.91 % 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	15.8 % (0.86 % lower than average)	vs	16.66 %
Percent of long-stay high-risk residents with pressure ulcers	2.3 % (10.28 % lower than average)	vs	12.58 %
Percent of long-stay residents who lose too much weight	3.7 % (8.13 % lower than average)	vs	11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	26.3 (79.3) % (18.24 % lower than average)	vs	44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	1.6 % (14.03 % lower than average)	vs	15.63 %
Percent of long-stay residents with a urinary tract infection	2.4 % (11.06 % lower than average)	vs	13.46 %
Percent of long-stay residents who have depressive symptoms	75.2 % (46.82 % higher than average)	vs	28.38 %
Percent of long-stay residents who were physically restrained	9.2 % (34.48 % lower than average)	vs	43.68 %
Percent of short-stay residents who self-report moderate to severe pain	26.1 % (1.08 % higher than average)	vs	25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	69 % (15.64 % lower than average)	vs	84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	70 % (13.94 % 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	4.6 % (10.92 % lower than average)	vs	15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication	33.2 % (7.81 % higher than average)	vs	25.39 %
Percent of long-stay residents whose need for help with daily activities has increased	3.9 % (19.8 % lower than average)	vs	23.70 %
Percent of long-stay residents who self-report moderate to severe pain	18.5 % (4.4 % higher than average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	3.6 % (5.62 % lower than average)	vs	9.22 %
Percent of long-stay residents who lose too much weight	4.4 % (4.1 % lower than average)	vs	8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	19.2 % (24.18 % lower than average)	vs	43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	1.7 % (8.95 % lower than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	3.1 % (6.48 % lower than average)	vs	9.58 %
Percent of long-stay residents who have depressive symptoms	1.3 % (18.56 % lower than average)	vs	19.86 %
Percent of long-stay residents who were physically restrained	8.8 % (29.73 % lower than average)	vs	38.53 %
Percent of long-stay residents experiencing one or more falls with major injury	2.5 % (8.23 % lower than average)	vs	10.73 %
Percent of short-stay residents who self-report moderate to severe pain	23.2 % (1.56 % lower than average)	vs	24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	78.3 % (3.14 % lower than average)	vs	81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	71.7 % (3.05 % lower than average)	vs	74.75 %
Percent of short-stay residents who newly received an antipsychotic medication	9.4 / 10.4 %