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TRINITY MISSION HEALTH & REHAB OF H S

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TRINITY MISSION HEALTH & REHAB OF H S VS
All other Nursing Homes USA
General
City HOLLY SPRINGS   vs 0% Nursing Homes USA have HOLLY SPRINGS
State attribute explanation MS   vs 1.3% Nursing Homes USA have MS
Street 1315 HIGHWAY 4 EAST  
Zip Code 38635  
Phone 6622521141  
Overall Star Rating
(0.89 higher than average)
vs
3.11

Health Inspections Star Rating
(1.17 higher than average)
vs
2.83

Nurse Staffing Star Rating
(0.17 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
120  (11.06 higher than average)
vs
108.94

Total Number of Residents
112  (20.75 higher than average)
vs
91.25

Percent of Occupied Beds
93 % (9.35 % higher than average)
vs
83.65 %

Health Survey Date 3/15/2012  
Fire Survey Date 3/15/2012  
Sprinkler Status Partially Sprinklered  vs 8.5% Nursing Homes USA have Partially Sprinklered
Program Participation Medicare And Medicaid  vs 91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Limited Liability Company  vs 1.1% Nursing Homes USA have For profit - Limited liability company
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 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
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
(5.48 lower than average)
vs
7.48

Staff Information
Number of Residents
112  (20.62 higher than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.42  (0.35 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
1.02  (0.18 higher than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.44  (0.15 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

Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 04/20/2011
date Of Correction: 05/12/2011 

Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 05/18/2009
date Of Correction: 06/11/2009 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
27.6 % (2.51 % higher than average)
vs
25.09 %

Percent of long-stay residents whose need for help with daily activities has increased
2.9 % (30.05 % lower than average)
vs
32.95 %

Percent of long-stay residents who self-report moderate to severe pain
11.3 % (5.36 % lower than average)
vs
16.66 %

Percent of long-stay high-risk residents with pressure ulcers
14.1 % (1.52 % higher than average)
vs
12.58 %

Percent of long-stay residents who lose too much weight
75.2 % (63.37 % higher than average)
vs
11.83 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
25.8 % (18.74 % lower than average)
vs
44.54 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
1.50 % (14.13 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection 14.7:1 % 
Percent of long-stay residents who have depressive symptoms
2.9 % (25.48 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
6.9 % (36.78 % lower than average)
vs
43.68 %

Percent of short-stay residents who self-report moderate to severe pain
8.8 % (16.22 % lower than average)
vs
25.02 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
100 % (15.36 % higher than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
100 % (16.06 % higher than average)
vs
83.94 %

Percent of short-stay residents who newly received an antipsychotic medication
7.7 % (38.2 % lower than average)
vs
45.90 %

Percent of long-stay residents experiencing one or more falls with major injury
1 % (14.52 % lower than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
29.1 % (3.71 % higher than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
4.6 % (19.1 % lower than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain
10.6 % (3.5 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
16 % (6.78 % higher than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
75.2 % (66.7 % higher than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
29.9 % (13.48 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
1.4 % (9.25 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
16.7 % (7.12 % higher than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms 2.6 / 3 % 
Percent of long-stay residents who were physically restrained 7.9:1 % 
Percent of long-stay residents experiencing one or more falls with major injury
2 % (8.73 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain 17.1:1 % 
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 %

Percent of short-stay residents who newly received an antipsychotic medication 10.3:1 % 


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