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WINDSOR MISSION OAKS

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WINDSOR MISSION OAKS VS
All other Nursing Homes USA
General
City SAN ANTONIO   vs 0.4% Nursing Homes USA have SAN ANTONIO
State attribute explanation TX   vs 7.6% Nursing Homes USA have TX
Street 3030 S ROOSEVELT AVE  
Zip Code 78214  
Phone 2109248151  
Overall Star Rating
(1.11 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
(1.69 higher than average)
vs
3.31

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

Number of Certified Beds
150  (41.06 higher than average)
vs
108.94

Total Number of Residents
133  (41.75 higher than average)
vs
91.25

Percent of Occupied Beds
89 % (5.35 % higher than average)
vs
83.65 %

Health Survey Date 7/22/2011  
Fire Survey Date 7/20/2011  
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 Non Profit - Other  vs 1.9% Nursing Homes USA have Non profit - Other
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
13  (5.52 higher than average)
vs
7.48

Staff Information
Number of Residents
133  (41.62 higher than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.2  (0.57 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.78  (0.06 lower than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
0.99  (0.6 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: Some
level Of Harm: 1
deficiency: Provide Housekeeping And Maintenance Services.
survey Date: 05/21/2010
date Of Correction: 06/21/2010 

Deficiency #2 Scope: Some
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: 06/04/2009
date Of Correction: 07/06/2009 

Mistreatment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 4
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 06/04/2009
date Of Correction: 07/06/2009 

Deficiency #2 Scope: Some
level Of Harm: 4
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 06/04/2009
date Of Correction: 07/06/2009 

Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Provide Or Obtain Dental Services For Each Resident.
survey Date: 10/15/2010
date Of Correction: 10/22/2010 

Resident Assessment Deficiencies
Deficiency #1 Scope: Some
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: 06/04/2009
date Of Correction: 07/06/2009 

Administration Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 1
deficiency: Post Nurse Staffing Information/data On A Daily Basis.
survey Date: 05/21/2010
date Of Correction: 06/21/2010 

Deficiency #2 Scope: Some
level Of Harm: 4
deficiency: Set Up An Ongoing Quality Assessment And Assurance Group To Review Quality Deficiencies Quarterly, And Develop Corrective Plans Of Action.
survey Date: 06/04/2009
date Of Correction: 07/06/2009 

Deficiency #3 Scope: Few
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: 06/04/2009
date Of Correction: 07/06/2009 

Deficiency #4 Scope: Some
level Of Harm: 4
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 06/04/2009
date Of Correction: 07/06/2009 

Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 4
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 06/04/2009
date Of Correction: 07/06/2009 

Deficiency #2 Scope: Few
level Of Harm: 4
deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.
survey Date: 06/04/2009
date Of Correction: 07/06/2009 

Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Keep The Rate Of Medication Errors (wrong Drug, Wrong Dose, Wrong Time) To Less Than 5%.
survey Date: 06/04/2009
date Of Correction: 07/06/2009 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
67.3 % (42.21 % higher than average)
vs
25.09 %

Percent of long-stay high-risk residents with pressure ulcers
1.7 % (10.88 % lower than average)
vs
12.58 %

Percent of long-stay residents who lose too much weight
1.7 % (10.13 % lower than average)
vs
11.83 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
40.7 % (3.84 % lower than average)
vs
44.54 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
0.9 % (14.73 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
5 % (8.46 % lower than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
1.7 % (26.68 % 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 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
68.9 % (43.51 % higher 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
13 % (1.1 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
1.2 % (8.02 % lower than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
3.1 % (5.4 % lower than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
36.9 % (6.48 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
1 % (9.65 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
2.8 % (6.78 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
9.1 % (10.76 % 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
23.9 % (13.17 % higher than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
11.1 % (13.66 % lower than average)
vs
24.76 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
32.7 (90.9) % (42.05 % lower than average)
vs
74.75 %



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