MOUNTAIN VILLA NURSING 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	2729 PORTER AVE
Zip Code	79930
Phone	9155662111
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	1 (2.17 lower than average)	vs	3.17	Compare similar Nurse Staffing Star Rating (1)
Quality Measures Star Rating	2 (1.31 lower than average)	vs	3.31	Compare similar Quality Measures Star Rating (2)
RN Only Star Rating	1 (2.17 lower than average)	vs	3.17	Compare similar RN Only Star Rating (1)
Number of Certified Beds	48 (60.94 lower than average)	vs	108.94	Compare similar Number of Certified Beds (48)
Total Number of Residents	47 (44.25 lower than average)	vs	91.25	Compare similar Total Number of Residents (47)
Percent of Occupied Beds	98 % (14.35 % higher than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (98) %
Health Survey Date	9/1/2011
Fire Survey Date	8/31/2011
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	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	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	1 (57.16 lower than average)	vs	58.16
Total Enforcement Actions Count	3 (53.31 lower than average)	vs	56.31
# of deficiencies	38 (30.52 higher than average)	vs	7.48

Staff Information
Number of Residents	47 (44.38 lower than average)	vs	91.38
Number of RN Hours Per Resident Per Day	0.24 (0.53 lower than average)	vs	0.77
Number of LPN/LVN Hours Per Resident Per Day	0.3 (0.54 lower than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	0.54 (1.05 lower than average)	vs	1.59
Number of CNA Hours Per Resident Per Day	0.01 (5.48 lower than average)	vs	5.49
Number Therapy Hours Per Resident Per Day	0.01 (0.09 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: 09/27/2011 date Of Correction: 12/09/2011
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 09/01/2011 date Of Correction: 09/30/2011
Deficiency #3		Scope: Many level Of Harm: 2 deficiency: Make Sure There Is A Pest Control Program To Prevent/deal With Mice, Insects, Or Other Pests. survey Date: 08/20/2010 date Of Correction: 09/25/2010
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 08/20/2010 date Of Correction: 09/25/2010
Deficiency #5		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: 08/20/2010 date Of Correction: 09/25/2010
Deficiency #6		Scope: Some level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 06/10/2010 date Of Correction: 08/10/2010
Deficiency #7		Scope: Some level Of Harm: 2 deficiency: Maintain Comfortable And Safe Temperature Levels. survey Date: 06/10/2010 date Of Correction: 08/10/2010
Deficiency #8		Scope: Some level Of Harm: 1 deficiency: Provide Housekeeping And Maintenance Services. survey Date: 06/10/2010 date Of Correction: 08/10/2010
Deficiency #9		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: 04/27/2010 date Of Correction: 05/28/2010

Mistreatment Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 03/30/2012 date Of Correction: 04/30/2012
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: 03/30/2012 date Of Correction: 04/30/2012
Deficiency #3		Scope: Many level Of Harm: 1 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 11/02/2011 date Of Correction: 12/02/2011
Deficiency #4		Scope: Many level Of Harm: 1 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: 11/02/2011 date Of Correction: 12/02/2011
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 09/01/2011 date Of Correction: 09/30/2011
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: 09/01/2011 date Of Correction: 09/30/2011
Deficiency #7		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 03/18/2011 date Of Correction: 04/20/2011
Deficiency #8		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: 03/18/2011 date Of Correction: 04/20/2011
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: 07/22/2010 date Of Correction: 08/11/2010
Deficiency #10		Scope: Many level Of Harm: 4 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 02/10/2010 date Of Correction: 03/20/2010
Deficiency #11		Scope: Many level Of Harm: 4 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: 02/10/2010 date Of Correction: 03/20/2010
Deficiency #12		Scope: Many level Of Harm: 4 deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others. survey Date: 02/10/2010 date Of Correction: 03/20/2010
Deficiency #13		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 10/22/2009 date Of Correction: 11/25/2009

Resident Rights Deficiencies
Deficiency #1		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: 07/18/2011 date Of Correction: 08/12/2011
Deficiency #2		Scope: Some 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: 05/09/2011 date Of Correction: 05/30/2011
Deficiency #3		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: 06/10/2010 date Of Correction: 08/10/2010
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Notify The Resident Or Provide Reasons For A Transfer Or Discharge. survey Date: 02/10/2010 date Of Correction: 03/20/2010

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: 11/02/2011 date Of Correction: 12/02/2011
Deficiency #2		Scope: Few level Of Harm: 3 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 07/18/2011 date Of Correction: 08/12/2011

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: 11/02/2011 date Of Correction: 12/02/2011
Deficiency #2		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: 04/27/2010 date Of Correction: 05/28/2010

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: 11/02/2011 date Of Correction: 12/02/2011
Deficiency #2		Scope: Some level Of Harm: 1 deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards. survey Date: 05/09/2011 date Of Correction: 05/30/2011
Deficiency #3		Scope: Many level Of Harm: 4 deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident . survey Date: 02/10/2010 date Of Correction: 03/20/2010
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: 1) Receive Registry Verification That A Nurse Aide Has Met The Required Training And Skills That The State Requires; And 2) Ensure Nurse Aides Receive The Required Retraining After 24 Months If Nursing Related Services Were Not Provided For Monetary Compensation survey Date: 10/22/2009 date Of Correction: 11/25/2009

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: 06/10/2010 date Of Correction: 08/10/2010
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Keep The Rate Of Medication Errors (wrong Drug, Wrong Dose, Wrong Time) To Less Than 5%. survey Date: 06/10/2010 date Of Correction: 08/10/2010

Nutrition and Dietary Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Make Sure That Special Or Therapeutic Diets Are Ordered By The Attending Doctor. survey Date: 07/18/2011 date Of Correction: 08/12/2011
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Provide Food In A Way That Meets A Resident's Needs. survey Date: 07/18/2011 date Of Correction: 08/12/2011

Quality Measures Q1
Percent of short-stay residents who newly received an antipsychotic medication		2 (43.9 lower than average)	vs	45.90

Quality Measures Q3
Deficiency #2	13.2 %
Percent of long-stay residents who received an antipsychotic medication	70.8 % (45.41 % higher than average)	vs	25.39 %
Percent of long-stay residents who self-report moderate to severe pain	24.1 % (10 % higher than average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	7.7 % (1.52 % lower than average)	vs	9.22 %
Percent of long-stay residents who lose too much weight	7.1 % (1.4 % lower than average)	vs	8.50 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	75.2 % (64.55 % higher than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	5.9 % (3.68 % lower than average)	vs	9.58 %
Percent of long-stay residents who have depressive symptoms	74.1 % (54.24 % higher than average)	vs	19.86 %
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	9.4 / 10.4 %