WILLIAMSBURG VILLAGE HEALTHCARE CAMPUS

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General
City	DESOTO	vs	0% Nursing Homes USA have DESOTO
State attribute explanation	TX	vs	7.6% Nursing Homes USA have TX	compare TX Nursing Homes USA
Street	941 SCOTLAND DR
Zip Code	75115
Phone	9725726200
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	3 (0.17 lower than average)	vs	3.17	Compare similar Nurse Staffing Star Rating (3)
Quality Measures Star Rating	4 (0.69 higher than average)	vs	3.31	Compare similar Quality Measures Star Rating (4)
RN Only Star Rating	2 (1.17 lower than average)	vs	3.17	Compare similar RN Only Star Rating (2)
Number of Certified Beds	242 (133.06 higher than average)	vs	108.94	Compare similar Number of Certified Beds (242)
Total Number of Residents	230 (138.75 higher than average)	vs	91.25	Compare similar Total Number of Residents (230)
Percent of Occupied Beds	95 % (11.35 % higher than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (95) %
Health Survey Date	5/25/2012
Fire Survey Date	5/24/2012
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	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	2 (56.16 lower than average)	vs	58.16
Total Enforcement Actions Count	2 (54.31 lower than average)	vs	56.31
# of deficiencies	34 (26.52 higher than average)	vs	7.48

Staff Information
Number of Residents	230 (138.62 higher than average)	vs	91.38
Number of RN Hours Per Resident Per Day	0.41 (0.36 lower than average)	vs	0.77
Number of LPN/LVN Hours Per Resident Per Day	1.25 (0.41 higher than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	1.66 (0.07 higher 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: Few level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 11/15/2011 date Of Correction: 12/09/2011
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Provide Clean Bed And Bath Linens That Are In Good Condition. survey Date: 08/12/2011 date Of Correction: 09/11/2011
Deficiency #3		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: 04/21/2011 date Of Correction: 05/21/2011
Deficiency #4		Scope: Many level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 03/10/2010 date Of Correction: 04/30/2010
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 08/28/2009 date Of Correction: 10/21/2009
Deficiency #6		Scope: Some level Of Harm: 1 deficiency: Provide Housekeeping And Maintenance Services. survey Date: 08/28/2009 date Of Correction: 10/21/2009
Deficiency #7		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: 04/02/2009 date Of Correction: 04/27/2009

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: 12/16/2010 date Of Correction: 12/17/2010
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: 12/16/2010 date Of Correction: 12/17/2010
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 08/05/2010 date Of Correction: 09/09/2010
Deficiency #4		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: 08/05/2010 date Of Correction: 09/09/2010
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: 03/10/2010 date Of Correction: 04/30/2010
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: 03/10/2010 date Of Correction: 04/30/2010
Deficiency #7		Scope: Few level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 03/06/2010 date Of Correction: 04/30/2010
Deficiency #8		Scope: Few 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: 03/06/2010 date Of Correction: 04/30/2010
Deficiency #9		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 08/28/2009 date Of Correction: 10/21/2009
Deficiency #10		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 06/05/2009 date Of Correction: 06/29/2009
Deficiency #11		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: 06/05/2009 date Of Correction: 06/29/2009

Resident Rights Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Try To Resolve Each Resident's Complaints Quickly. survey Date: 03/10/2010 date Of Correction: 04/30/2010
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: 03/10/2010 date Of Correction: 04/30/2010

Quality Care Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 03/31/2011 date Of Correction: 04/29/2011
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Make Sure That Each Resident Who Enters The Nursing Home Without A Catheter Is Not Given A Catheter, And Receive Proper Services To Prevent Urinary Tract Infections And Restore Normal Bladder Function. survey Date: 03/10/2010 date Of Correction: 04/30/2010
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Develop Policies And Procedures For Influenza And Pneumococcal Immunizations. survey Date: 08/28/2009 date Of Correction: 10/21/2009
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality. survey Date: 08/28/2009 date Of Correction: 10/21/2009

Administration Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Make Sure That Nurse Aides Show They Have The Skills And Techniques To Be Able To Care For Residents' Needs. survey Date: 03/10/2010 date Of Correction: 04/30/2010
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: 1) Review The Work Of Each Nurse Aide Every Year; And 2) Give Regular In-service Training Based Upon These Reviews. survey Date: 03/10/2010 date Of Correction: 04/30/2010
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident . survey Date: 03/10/2010 date Of Correction: 04/30/2010
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards. survey Date: 08/28/2009 date Of Correction: 10/21/2009
Deficiency #5		Scope: Some level Of Harm: 1 deficiency: 1) Review The Work Of Each Nurse Aide Every Year; And 2) Give Regular In-service Training Based Upon These Reviews. survey Date: 08/28/2009 date Of Correction: 10/21/2009
Deficiency #6		Scope: Some level Of Harm: 3 deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident . survey Date: 08/28/2009 date Of Correction: 10/21/2009
Deficiency #7		Scope: Some level Of Harm: 2 deficiency: Employ Qualified Full-time, Part-time Or Consultant Professionals That Must Be Licensed, Certified, Or Registered Staff To Give Needed Services. survey Date: 06/05/2009 date Of Correction: 06/06/2009

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: 03/10/2010 date Of Correction: 04/30/2010
Deficiency #2		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: 08/28/2009 date Of Correction: 10/21/2009
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being. survey Date: 06/05/2009 date Of Correction: 06/12/2009

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication	36.1 % (11.01 % higher than average)	vs	25.09 %
Percent of long-stay residents whose need for help with daily activities has increased	2.4 % (30.55 % lower than average)	vs	32.95 %
Percent of long-stay residents who self-report moderate to severe pain	0.9 % (15.76 % lower than average)	vs	16.66 %
Percent of long-stay high-risk residents with pressure ulcers	8.7 % (3.88 % lower than average)	vs	12.58 %
Percent of long-stay residents who lose too much weight	11.5 % (0.33 % lower than average)	vs	11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	52.2 % (7.66 % higher than average)	vs	44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	2 % (13.63 % lower than average)	vs	15.63 %
Percent of long-stay residents with a urinary tract infection	8.6:1 %
Percent of long-stay residents who have depressive symptoms	75.2 % (46.82 % higher 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	11.6:1 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	81.5 % (3.14 % lower than average)	vs	84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	78.1 % (5.84 % lower than average)	vs	83.94 %
Percent of short-stay residents who newly received an antipsychotic medication	75.2 (29.3 higher than average)	vs	45.90
Percent of long-stay residents experiencing one or more falls with major injury	1.7 % (13.82 % lower than average)	vs	15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication	34.6 % (9.21 % higher than average)	vs	25.39 %
Percent of long-stay residents whose need for help with daily activities has increased	2.1 % (21.6 % lower than average)	vs	23.70 %
Percent of long-stay residents who self-report moderate to severe pain	3.2 % (10.9 % lower than average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	9.5 % (0.28 % higher than average)	vs	9.22 %
Percent of long-stay residents who lose too much weight	8.2 % (0.3 % lower than average)	vs	8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	51.9 % (8.52 % higher than average)	vs	43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	2.8 % (7.85 % lower than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	9.8 % (0.22 % higher than average)	vs	9.58 %
Percent of long-stay residents who have depressive symptoms	0.5 - 2.0 % (19.36 % 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	1.8 % (8.93 % lower than average)	vs	10.73 %
Percent of short-stay residents who self-report moderate to severe pain	16.4 % (8.36 % lower than average)	vs	24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	78.9 % (2.54 % lower than average)	vs	81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	76.2 % (1.45 % higher than average)	vs	74.75 %
Percent of short-stay residents who newly received an antipsychotic medication	21.2:1 %