| General |
| City |
| Columbia |
Hilton Head Island |
| State attribute explanation |
| Sc |
Sc |
| Street |
| 2451 Forest Drive |
120 Lamotte Drive |
| Zip Code |
| 29,204 |
29,926 |
| Phone |
| 8,032,545,960 |
8,436,816,006 |
|
Overall Star Rating |
| 2 |
2 |
|
Health Inspections Star Rating |
| 1 |
1 |
|
Nurse Staffing Star Rating |
| 4 |
5 |
|
Quality Measures Star Rating |
| 4 |
4 |
|
RN Only Star Rating |
| 3 |
5 |
|
Number of Certified Beds |
| 171 |
88 |
|
Total Number of Residents |
| 165 |
50 |
|
Percent of Occupied Beds |
| 96 % |
57 % |
| Health Survey Date |
| 7/27/2011 |
9/14/2011 |
| Fire Survey Date |
| 7/27/2011 |
9/13/2011 |
| Sprinkler Status |
| Fully Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| For Profit - Corporation |
For Profit - Corporation |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| Yes |
Yes |
| Resident and Family Councils |
| Resident |
Resident |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| No |
No |
| Special Focus Facility? |
| No |
No |
| Civil Money Penalty Count |
| 4 |
1 |
| Total Enforcement Actions Count |
| 4 |
1 |
| # of deficiencies |
| 17 |
11 |
|
| Staff Information |
| Number of Residents |
| 165 |
50 |
| Number of RN Hours Per Resident Per Day |
| 0.59 |
1.50 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 1.14 |
1.95 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.73 |
3.45 |
| Number of CNA Hours Per Resident Per Day |
| 0.01 |
0.23 |
| Number Therapy Hours Per Resident Per Day |
| 0.01 |
0.23 |
| Environmental Deficiencies |
| Deficiency #1 |
| Scope: Manylevel Of Harm: 2deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 07/27/2011date Of Correction: 08/26/2011 |
|
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 4deficiency: Make Sure That A Working Call System Is Available In Each Resident's Room Or Bathroom And Bathing Area.survey Date: 12/07/2010date Of Correction: 12/08/2010 |
|
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 10/22/2009date Of Correction: 11/22/2009 |
|
| Mistreatment Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 4deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 04/12/2011date Of Correction: 06/03/2011 |
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: 01/25/2012date Of Correction: 03/01/2012 |
| Resident Rights Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Keep Each Resident's Personal And Medical Records Private And Confidential.survey Date: 07/27/2011date Of Correction: 08/26/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Let The Resident Refuse Treatment Or Refuse To Take Part In An Experiment And Formulate Advance Directives.survey Date: 01/25/2012date Of Correction: 03/01/2012 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: 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: 07/27/2011date Of Correction: 08/26/2011 |
Scope: Fewlevel Of Harm: 3deficiency: Let The Resident Or The Resident's Legal Representative The Right To Access Or Purchase Copies Of All Records.survey Date: 01/25/2012date Of Correction: 03/01/2012 |
| Deficiency #3 |
| Scope: Manylevel Of Harm: 1deficiency: Give Each Resident A Notice Of Rights, Rules, Services And Charges. Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items And Services Medicaid Covers And Which The Resident Must Pay For.survey Date: 07/27/2011date Of Correction: 08/26/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Give The Resident's Representative The Ability To Exercise The Resident's Rights.survey Date: 01/25/2012date Of Correction: 03/01/2012 |
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 4deficiency: 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: 04/12/2011date Of Correction: 06/03/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Follow Policies And Procedures To Convey The Resident's Personal Funds To The Appropriate Party Responsible After The Resident's Death.survey Date: 09/14/2011date Of Correction: 09/23/2011 |
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: 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: 07/27/2011date Of Correction: 08/26/2011 |
Scope: Somelevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 01/25/2012date Of Correction: 03/01/2012 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 07/27/2011date Of Correction: 08/26/2011 |
Scope: Fewlevel Of Harm: 4deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 06/22/2011date Of Correction: 06/14/2011 |
| Deficiency #3 |
| Scope: Somelevel Of Harm: 4deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses.survey Date: 04/12/2011date Of Correction: 06/03/2011 |
Scope: Fewlevel Of Harm: 4deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 06/22/2011date Of Correction: 06/14/2011 |
| Deficiency #4 |
| Scope: Somelevel Of Harm: 4deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 04/12/2011date Of Correction: 06/03/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 10/21/2009date Of Correction: 11/09/2009 |
| Deficiency #5 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.survey Date: 10/22/2009date Of Correction: 11/22/2009 |
|
| 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: 12/07/2010date Of Correction: 12/22/2010 |
|
| Deficiency #2 |
| 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: 10/22/2009date Of Correction: 11/22/2009 |
|
| Administration Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 4deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .survey Date: 12/07/2010date Of Correction: 12/08/2010 |
Scope: Somelevel Of Harm: 2deficiency: Give Or Get Quality Lab Services/tests In A Timely Manner To Meet The Needs Of Residents.survey Date: 09/14/2011date Of Correction: 09/23/2011 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 4deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .survey Date: 06/22/2011date Of Correction: 06/14/2011 |
| Pharmacy Service Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.survey Date: 07/27/2011date Of Correction: 08/26/2011 |
|
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 27.9 % |
22.7 (72.9) |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 0.8 % |
3.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 5.4 % |
|
| Percent of long-stay high-risk residents with pressure ulcers |
| 8 % |
3.3 % |
| Percent of long-stay residents who lose too much weight |
| 5.8 % |
9.3 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 36 % |
|
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 2.7 % |
6.2 % |
| Percent of long-stay residents with a urinary tract infection |
| 4.3 % |
4.8 % |
| Percent of long-stay residents who have depressive symptoms |
| 4.2 % |
75.2 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
4.5 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 15.6 % |
5.5 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 82.2 % |
75 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 86.1 % |
80.2 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 |
1.50 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 2.8 % |
2.3 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 25.6 (78.1) |
24.8 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 1.1 % |
1.9 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 6.7 % |
75.2 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 9.6 % |
9.6 % |
| Percent of long-stay residents who lose too much weight |
| 5.6:1 |
9.2 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 31.6 % |
|
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 4.5 % |
4.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 3.5 % |
3.4 % |
| Percent of long-stay residents who have depressive symptoms |
| 2.7 % |
1.7 % |
| Percent of long-stay residents who were physically restrained |
| 0.9 % |
6.6 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 2.7 % |
2.5 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 14.5 % |
3.8 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 67.6 % |
57.5 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 80.9 % |
86.1 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 17.5 % |
17.8:1 |