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SILVER SPRINGS REHABILITATION AND HEALTHCARE

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SILVER SPRINGS REHABILITATION AND HEALTHCARE VS
All other Nursing Homes USA
General
City Houston  vs 0.4% Nursing Homes USA have Houston
State attribute explanation TX   vs 7.6% Nursing Homes USA have TX
Street 12350 WOOD BAYOU DR  
Zip Code 77013  
Phone 7134530446  
Overall Star Rating
(2.11 lower than average)
vs
3.11

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

Nurse Staffing Star Rating
(0.17 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
150  (41.06 higher than average)
vs
108.94

Total Number of Residents
97  (5.75 higher than average)
vs
91.25

Percent of Occupied Beds
65 % (18.65 % lower than average)
vs
83.65 %

Health Survey Date 5/27/2011  
Fire Survey Date 5/26/2011  
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 - Individual  vs 3.5% Nursing Homes USA have For profit - Individual
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 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
(56.16 lower than average)
vs
58.16

Total Enforcement Actions Count
(53.31 lower than average)
vs
56.31

# of deficiencies
11  (3.52 higher than average)
vs
7.48

Staff Information
Number of Residents
109  (17.62 higher than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.69  (0.08 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.64  (0.2 lower than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.33  (0.26 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: Some
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 10/21/2011
date Of Correction: 11/02/2011 

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: 10/21/2011
date Of Correction: 10/24/2011 

Deficiency #3 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: 07/30/2009
date Of Correction: 08/07/2009 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 04/03/2009
date Of Correction: 05/28/2009 

Mistreatment Deficiencies
Deficiency #1 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: 05/27/2011
date Of Correction: 06/20/2011 

Deficiency #2 Scope: Few
level Of Harm: 3
deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.
survey Date: 05/27/2011
date Of Correction: 06/20/2011 

Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment.
survey Date: 05/27/2010
date Of Correction: 06/30/2010 

Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Determine If It Is Safe For The Resident To Self-administer Drugs.
survey Date: 05/27/2010
date Of Correction: 06/30/2010 

Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses.
survey Date: 10/21/2011
date Of Correction: 11/02/2011 

Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Choose A Doctor To Serve As The Medical Director To Create Resident Care Policies And Coordinate Medical Care In The Facility.
survey Date: 07/16/2010
date Of Correction: 08/06/2010 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 04/03/2009
date Of Correction: 05/27/2009 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
18.9 % (6.19 % lower than average)
vs
25.09 %

Percent of long-stay residents whose need for help with daily activities has increased
0.8 % (32.15 % lower than average)
vs
32.95 %

Percent of long-stay residents who self-report moderate to severe pain 12.1:1 % 
Percent of long-stay high-risk residents with pressure ulcers 11.8:1 % 
Percent of long-stay residents who lose too much weight
10 % (1.83 % lower than average)
vs
11.83 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
1.9 % (13.73 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
9.8 % (3.66 % lower than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
2.4 % (25.98 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
3.3 % (40.38 % lower than average)
vs
43.68 %

Percent of short-stay residents who self-report moderate to severe pain 8.6:1 % 
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
72.3 % (12.34 % lower than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
68.7 % (15.24 % lower than average)
vs
83.94 %

Percent of short-stay residents who newly received an antipsychotic medication 5.6:1 % 
Percent of long-stay residents experiencing one or more falls with major injury
1.1 % (14.42 % lower than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
23.6 % (1.79 % lower than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
1.8 % (21.9 % lower than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain 12.8:1 % 
Percent of long-stay high-risk residents with pressure ulcers
13.5 % (4.28 % higher than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight 7.9:1 % 
Percent of long-stay low-risk residents who lose control of their bowels or bladder
65.4 % (22.02 % higher than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
0.9 % (9.75 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
8.2 % (1.38 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
3.1 % (16.76 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
4.2 % (34.33 % lower than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
0.8 % (9.93 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
16.5 % (8.26 % lower than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
69.7 % (11.74 % lower than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
65.6 % (9.15 % lower than average)
vs
74.75 %

Percent of short-stay residents who newly received an antipsychotic medication
2.8 % (14.54 % lower than average)
vs
17.34 %



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