NORTH CHURCH NURSING & REHAB

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General
City	JACKSONVILLE	vs	0.3% Nursing Homes USA have JACKSONVILLE
State attribute explanation	IL	vs	5% Nursing Homes USA have IL	compare IL Nursing Homes USA
Street	1021 NORTH CHURCH STREET
Zip Code	62650
Phone	2172454174
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	4 (0.69 higher than average)	vs	3.31	Compare similar Quality Measures Star Rating (4)
RN Only Star Rating	1 (2.17 lower than average)	vs	3.17	Compare similar RN Only Star Rating (1)
Number of Certified Beds	113 (4.06 higher than average)	vs	108.94	Compare similar Number of Certified Beds (113)
Total Number of Residents	82 (9.25 lower than average)	vs	91.25	Compare similar Total Number of Residents (82)
Percent of Occupied Beds	73 % (10.65 % lower than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (73) %
Health Survey Date	11/4/2011
Fire Survey Date	12/9/2011
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?	Yes	vs	54.9% Nursing Homes USA 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?	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	4 (54.16 lower than average)	vs	58.16
Total Enforcement Actions Count	5 (51.31 lower than average)	vs	56.31
# of deficiencies	38 (30.52 higher than average)	vs	7.48

Staff Information
Number of Residents	82 (9.38 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	0.65 (0.19 lower than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	0.9 (0.69 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: Few level Of Harm: 2 deficiency: Keep All Essential Equipment Working Safely. survey Date: 01/03/2012 date Of Correction: 01/13/2012
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: 10/07/2011 date Of Correction: 10/08/2011
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: 04/06/2011 date Of Correction: 04/07/2011
Deficiency #4		Scope: Many level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 01/08/2010 date Of Correction: 01/08/2010
Deficiency #5		Scope: Few level Of Harm: 4 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 10/22/2009 date Of Correction: 11/06/2009
Deficiency #6		Scope: Few level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 09/23/2009 date Of Correction: 10/14/2009
Deficiency #7		Scope: Some level Of Harm: 1 deficiency: Provide Housekeeping And Maintenance Services. survey Date: 06/03/2009 date Of Correction: 06/09/2009
Deficiency #8		Scope: Some level Of Harm: 2 deficiency: Make Sure That The Nursing Home Area Is Safe, Easy To Use, Clean And Comfortable For Residents, Staff And The Public. survey Date: 05/19/2009 date Of Correction: 05/22/2009
Deficiency #9		Scope: Some level Of Harm: 2 deficiency: Provide Clean Bed And Bath Linens That Are In Good Condition. survey Date: 05/19/2009 date Of Correction: 06/11/2009

Mistreatment Deficiencies
Deficiency #1		Scope: Few level Of Harm: 4 deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property. survey Date: 10/22/2009 date Of Correction: 10/23/2009
Deficiency #2		Scope: Some level Of Harm: 4 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 06/03/2009 date Of Correction: 06/05/2009
Deficiency #3		Scope: Some 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: 06/03/2009 date Of Correction: 06/05/2009
Deficiency #4		Scope: Some level Of Harm: 4 deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others. survey Date: 06/03/2009 date Of Correction: 06/05/2009

Resident Rights Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Reasonably Accommodate The Needs And Preferences Of Each Resident. survey Date: 01/03/2012 date Of Correction: 01/13/2012
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: 05/05/2011 date Of Correction: 05/06/2011

Quality Care Deficiencies
Deficiency #1		Scope: Many level Of Harm: 2 deficiency: Use A Registered Nurse At Least 8 Hours A Day, 7 Days A Week. survey Date: 03/13/2012 date Of Correction: 03/13/2012
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: 03/13/2012 date Of Correction: 03/15/2012
Deficiency #3		Scope: Few level Of Harm: 2 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 01/23/2012 date Of Correction: 01/30/2012
Deficiency #4		Scope: Few level Of Harm: 3 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 08/31/2011 date Of Correction: 09/01/2011
Deficiency #5		Scope: Few level Of Harm: 2 deficiency: Give Proper Treatment To Residents With Feeding Tubes To Prevent Problems (such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-pharyngeal Ulcers) And Help Restore Eating Skills, If Possible. survey Date: 05/05/2011 date Of Correction: 05/06/2011
Deficiency #6		Scope: Some level Of Harm: 2 deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care. survey Date: 03/04/2011 date Of Correction: 03/11/2011
Deficiency #7		Scope: Few level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 12/18/2009 date Of Correction: 12/21/2009
Deficiency #8		Scope: Some level Of Harm: 2 deficiency: Give Proper Treatment To Residents With Feeding Tubes To Prevent Problems (such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-pharyngeal Ulcers) And Help Restore Eating Skills, If Possible. survey Date: 10/22/2009 date Of Correction: 11/09/2009
Deficiency #9		Scope: Few level Of Harm: 3 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 10/22/2009 date Of Correction: 11/09/2009
Deficiency #10		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: 10/22/2009 date Of Correction: 11/09/2009
Deficiency #11		Scope: Few level Of Harm: 2 deficiency: Give Proper Treatment To Residents With Feeding Tubes To Prevent Problems (such As Aspiration Pneumonia, Diarrhea, Vomiting, Dehydration, Metabolic Abnormalities, Nasal-pharyngeal Ulcers) And Help Restore Eating Skills, If Possible. survey Date: 09/23/2009 date Of Correction: 11/09/2009
Deficiency #12		Scope: Few level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 09/23/2009 date Of Correction: 12/21/2009
Deficiency #13		Scope: Few level Of Harm: 2 deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality. survey Date: 09/23/2009 date Of Correction: 10/14/2009
Deficiency #14		Scope: Some level Of Harm: 2 deficiency: Use A Registered Nurse At Least 8 Hours A Day, 7 Days A Week. survey Date: 06/03/2009 date Of Correction: 08/01/2009
Deficiency #15		Scope: Few level Of Harm: 2 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 06/03/2009 date Of Correction: 07/30/2009

Resident Assessment Deficiencies
Deficiency #1		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: 10/07/2011 date Of Correction: 10/08/2011
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional. survey Date: 10/07/2011 date Of Correction: 10/08/2011
Deficiency #3		Scope: Few level Of Harm: 2 deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity. survey Date: 08/31/2011 date Of Correction: 09/01/2011

Pharmacy Service Deficiencies
Deficiency #1		Scope: Few level Of Harm: 3 deficiency: Make Sure That Residents Are Safe From Serious Medication Errors. survey Date: 03/13/2012 date Of Correction: 03/13/2012
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Make Sure That Residents Are Safe From Serious Medication Errors. survey Date: 08/31/2011 date Of Correction: 09/01/2011
Deficiency #3		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: 09/23/2009 date Of Correction: 10/14/2009
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Keep The Rate Of Medication Errors (wrong Drug, Wrong Dose, Wrong Time) To Less Than 5%. survey Date: 09/23/2009 date Of Correction: 09/24/2009

Nutrition and Dietary Deficiencies
Deficiency #1		Scope: Few level Of Harm: 4 deficiency: Provide Food In A Way That Meets A Resident's Needs. survey Date: 10/22/2009 date Of Correction: 11/06/2009

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication	63 % (37.91 % 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	13.2 % (3.46 % lower than average)	vs	16.66 %
Percent of long-stay high-risk residents with pressure ulcers	8.6:1 %
Percent of long-stay residents who lose too much weight	6 % (5.83 % lower than average)	vs	11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	31.4 (88.5) % (13.14 % lower than average)	vs	44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	3.5 % (12.13 % lower than average)	vs	15.63 %
Percent of long-stay residents with a urinary tract infection	6 % (7.46 % lower than average)	vs	13.46 %
Percent of long-stay residents who have depressive symptoms	14.3 % (14.08 % lower than average)	vs	28.38 %
Percent of long-stay residents who were physically restrained	75.2 % (31.52 % higher than average)	vs	43.68 %
Percent of short-stay residents who self-report moderate to severe pain	30.8 % (5.78 % higher than average)	vs	25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	96.6 % (11.96 % higher than average)	vs	84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	93.9 % (9.96 % higher than average)	vs	83.94 %
Percent of short-stay residents who newly received an antipsychotic medication	1 (44.9 lower 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	65.9 % (40.51 % higher than average)	vs	25.39 %
Percent of long-stay residents whose need for help with daily activities has increased	3.1 % (20.6 % lower than average)	vs	23.70 %
Percent of long-stay residents who self-report moderate to severe pain	14.1 % (equals average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	11.3 % (2.08 % higher than average)	vs	9.22 %
Percent of long-stay residents who lose too much weight	5.8 % (2.7 % lower than average)	vs	8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	28.3 % (15.08 % lower than average)	vs	43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	2.3 % (8.35 % lower than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	4.5 % (5.08 % lower than average)	vs	9.58 %
Percent of long-stay residents who have depressive symptoms	12.4-2413.6-24 % (7.46 % lower than average)	vs	19.86 %
Percent of long-stay residents who were physically restrained	75.2 % (36.67 % higher than average)	vs	38.53 %
Percent of long-stay residents experiencing one or more falls with major injury	1.3 % (9.43 % lower than average)	vs	10.73 %
Percent of short-stay residents who self-report moderate to severe pain	23.8:1 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	91.7 % (10.26 % higher than average)	vs	81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	97.1 % (22.35 % higher than average)	vs	74.75 %