| General |
| City |
| Union |
Seneca |
| State attribute explanation |
| Sc |
Sc |
| Street |
| 1817 Jonesville Highway |
101 Lila Doyle Drive |
| Zip Code |
| 29,379 |
29,672 |
| Phone |
| 8,644,275,187 |
8,648,857,675 |
|
Overall Star Rating |
| 2 |
1 |
|
Health Inspections Star Rating |
| 1 |
1 |
|
Nurse Staffing Star Rating |
| 4 |
3 |
|
Quality Measures Star Rating |
| 4 |
2 |
|
RN Only Star Rating |
| 3 |
3 |
|
Number of Certified Beds |
| 113 |
120 |
|
Total Number of Residents |
| 112 |
116 |
|
Percent of Occupied Beds |
| 99 % |
97 % |
| Health Survey Date |
| 12/14/2011 |
11/30/2011 |
| Fire Survey Date |
| 12/14/2011 |
12/1/2011 |
| Sprinkler Status |
| Fully Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| Government - Hospital District |
Non Profit - Corporation |
| Located Within a Hospital? |
| No |
Yes |
| Multi Nursing Home Ownership? |
| No |
No |
| Resident and Family Councils |
| Both |
Resident |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| No |
No |
| Special Focus Facility? |
| No |
No |
| Civil Money Penalty Count |
| 6 |
1 |
| Total Enforcement Actions Count |
| 7 |
1 |
| # of deficiencies |
| 13 |
|
|
| Staff Information |
| Number of Residents |
| 112 |
116 |
| Number of RN Hours Per Resident Per Day |
| 0.56 |
0.66 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.49 |
0.93 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.04 |
1.59 |
| Number of CNA Hours Per Resident Per Day |
| 0.02 |
0.11 |
| Number Therapy Hours Per Resident Per Day |
| 0.02 |
0.11 |
| Mistreatment Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment.survey Date: 12/14/2011date Of Correction: 01/26/2012 |
|
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 09/20/2011date Of Correction: 10/28/2011 |
|
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: 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: 09/20/2011date Of Correction: 10/28/2011 |
|
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 3deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 08/13/2009date Of Correction: 09/12/2009 |
|
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being.survey Date: 09/20/2011date Of Correction: 10/28/2011 |
|
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses.survey Date: 05/17/2010date Of Correction: 06/17/2010 |
|
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 05/17/2010date Of Correction: 06/17/2010 |
|
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 3deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.survey Date: 08/13/2009date Of Correction: 09/12/2009 |
|
| Resident Assessment Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.survey Date: 12/14/2011date Of Correction: 01/26/2012 |
|
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional.survey Date: 12/14/2011date Of Correction: 01/26/2012 |
|
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 3deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.survey Date: 08/13/2009date Of Correction: 09/12/2009 |
|
| Administration Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 3deficiency: Set Up An Ongoing Quality Assessment And Assurance Group To Review Quality Deficiencies Quarterly, And Develop Corrective Plans Of Action.survey Date: 08/13/2009date Of Correction: 09/12/2009 |
|
| Pharmacy Service Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.survey Date: 05/17/2010date Of Correction: 06/17/2010 |
|
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 17.5 % |
19.8 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 2 % |
1.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 1.3 % |
15.1 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 1.50 % |
5 % |
| Percent of long-stay residents who lose too much weight |
| 7.8 % |
14.6 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
|
61 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 1.2 % |
3.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 11.8:1 |
10.1:1 |
| Percent of long-stay residents who have depressive symptoms |
| 3 % |
2.20 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
|
29.4 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 96.7 % |
95.4 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 93.8 % |
96.9 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 13 % |
0.8 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 4.9 % |
5.6:1 |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 16.2 % |
22.5 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 2.3 % |
2.1 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 6.3 % |
15.1 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 1.9 % |
6.3 % |
| Percent of long-stay residents who lose too much weight |
| 9.1 % |
9 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 38.1 % |
57.5 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 1.4 % |
2.9 % |
| Percent of long-stay residents with a urinary tract infection |
| 8.5 % |
8.6:1 |
| Percent of long-stay residents who have depressive symptoms |
| 6.5 % |
0.7 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 4 % |
5.9 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 9.4 / 10.4 |
31.8 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 97.9 % |
93.8 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 94.9 % |
93.5 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 24.7 % |
22.8 % |