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THREE RIVERS NURSING HOME LLC

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THREE RIVERS NURSING HOME LLC VS
All other Nursing Homes USA
General
City THREE RIVERS   vs 0% Nursing Homes USA have THREE RIVERS
State attribute explanation TX   vs 7.6% Nursing Homes USA have TX
Street 1717 45THST  
Zip Code 78071  
Phone 3617862256  
Overall Star Rating
(2.11 lower than average)
vs
3.11

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

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

Quality Measures Star Rating
(1.31 lower than average)
vs
3.31

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

Number of Certified Beds
74  (34.94 lower than average)
vs
108.94

Total Number of Residents
39  (52.25 lower than average)
vs
91.25

Percent of Occupied Beds
53 % (30.65 % lower than average)
vs
83.65 %

Health Survey Date 10/27/2011  
Fire Survey Date 10/26/2011  
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 - Corporation  vs 56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  vs 93.6% Nursing Homes USA 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 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
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
(0.48 lower than average)
vs
7.48

Staff Information
Number of Residents
39  (52.38 lower than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.38  (0.39 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.57  (0.27 lower than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
0.95  (0.64 lower than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
75.2  (69.71 higher than average)
vs
5.49

Environmental Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 04/10/2010
date Of Correction: 05/05/2010 

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: 01/26/2012
date Of Correction: 02/15/2012 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.
survey Date: 01/26/2012
date Of Correction: 02/15/2012 

Resident Rights Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Listen To The Resident Or Family Groups Or Act On Their Complaints Or Suggestions.
survey Date: 01/26/2012
date Of Correction: 02/15/2012 

Deficiency #2 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: 01/26/2012
date Of Correction: 02/15/2012 

Quality Care Deficiencies
Deficiency #1 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: 01/26/2012
date Of Correction: 02/15/2012 

Administration Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 1
deficiency: Ensure The Activities Program Is Directed By A Qualified Professional.
survey Date: 12/29/2011
date Of Correction: 01/14/2012 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
5.9 % (19.19 % lower than average)
vs
25.09 %

Percent of long-stay residents who self-report moderate to severe pain
4.6 % (12.06 % lower than average)
vs
16.66 %

Percent of long-stay residents who lose too much weight
20 % (8.17 % higher than average)
vs
11.83 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
5.5 % (10.13 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection 17.1:1 % 
Percent of long-stay residents who have depressive symptoms
16.7 % (11.68 % 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 long-stay residents experiencing one or more falls with major injury
5.4 % (10.12 % lower than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
6.7 % (18.69 % 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
7.2 % (6.9 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
20.7 (69.3) % (11.48 % higher than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight 14.7:1 % 
Percent of long-stay residents who have had a catheter inserted and left in their bladder
4 % (6.65 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection 14.7:1 % 
Percent of long-stay residents who have depressive symptoms
10.9 % (8.96 % 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
7.1 % (3.63 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
25 % (0.24 % higher than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
100 % (18.56 % higher than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
100 % (25.25 % higher than average)
vs
74.75 %



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