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CASA MARIA HEALTHCARE CENTER AND PECOS VALLEY REHA

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CASA MARIA HEALTHCARE CENTER AND PECOS VALLEY REHA VS
Nursing Homes USA
General
City ROSWELL   0% Nursing Homes USA have ROSWELL
State attribute explanation NM   0.5% Nursing Homes USA have NM
Street 1601 SOUTH MAIN STREET  
Zip Code 88203  
Phone 5756236008  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
118 
108.94
Total Number of Residents
77 
91.25
Percent of Occupied Beds
65 %
83.65 %
Health Survey Date 2/14/2012  
Fire Survey Date 2/8/2012  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Limited Liability Company  1.1% Nursing Homes USA have For profit - Limited liability company
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
58.16
Total Enforcement Actions Count
56.31
# of deficiencies
24 
7.48
Staff Information
Number of Residents
77 
91.38
Number of RN Hours Per Resident Per Day
1.29 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.32 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.61 
1.59
Number of CNA Hours Per Resident Per Day
0.16 
5.49
Number Therapy Hours Per Resident Per Day
0.16 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 02/14/2012
date Of Correction: 05/10/2012 
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: 03/17/2010
date Of Correction: 04/26/2010 
Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 4
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 03/17/2010
date Of Correction: 04/26/2010 
Deficiency #2 Scope: Few
level Of Harm: 4
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 03/17/2010
date Of Correction: 04/26/2010 
Resident Rights Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Try To Resolve Each Resident's Complaints Quickly.
survey Date: 02/11/2011
date Of Correction: 03/18/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Tell The Resident Or The Resident's Representative In Writing How Long The Nursing Home Will Hold The Resident's Bed.
survey Date: 03/17/2010
date Of Correction: 04/26/2010 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Notify The Resident Or Provide Reasons For A Transfer Or Discharge.
survey Date: 03/17/2010
date Of Correction: 04/28/2010 
Deficiency #4 Scope: Few
level Of Harm: 3
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: 03/17/2010
date Of Correction: 04/28/2010 
Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 02/14/2012
date Of Correction: 05/10/2012 
Deficiency #2 Scope: Some
level Of Harm: 4
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 10/17/2011
date Of Correction: 12/14/2011 
Deficiency #3 Scope: Some
level Of Harm: 4
deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.
survey Date: 10/17/2011
date Of Correction: 12/14/2011 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 02/11/2011
date Of Correction: 03/18/2011 
Deficiency #5 Scope: Some
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 02/11/2011
date Of Correction: 03/18/2011 
Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 03/17/2010
date Of Correction: 04/26/2010 
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: 02/14/2012
date Of Correction: 05/10/2012 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Make Sure That All Needed Doctor Visits Are Made Personally By A Doctor, As Required. After Initial Doctor Visit, Care May Be Alternated By A Physician Assistant (pa) Or Nurse Practitioner (np).
survey Date: 10/17/2011
date Of Correction: 12/14/2011 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Make Sure That Doctors Visit Residents Regularly, As Required.
survey Date: 10/17/2011
date Of Correction: 12/14/2011 
Deficiency #4 Scope: Few
level Of Harm: 3
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 03/17/2010
date Of Correction: 04/26/2010 
Deficiency #5 Scope: Few
level Of Harm: 3
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 03/17/2010
date Of Correction: 04/26/2010 
Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.
survey Date: 01/12/2010
date Of Correction: 04/26/2010 
Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Give Or Get X-rays And Other Tests In A Timely Manner To Meet The Needs Of Residents.
survey Date: 02/11/2011
date Of Correction: 03/18/2011 
Deficiency #2 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: 03/17/2010
date Of Correction: 04/26/2010 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Ensure That All Nurse Aids Who Have Worked Less Than 4 Months Are Enrolled In Appropriate Training Or Have Been Deemed Competent To Provide Nursing And Nursing Related Services.
survey Date: 03/17/2010
date Of Correction: 04/26/2010 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Some
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: 10/17/2011
date Of Correction: 12/14/2011 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
31.8 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
0.6 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain
8.7 %
16.66 %
Percent of long-stay high-risk residents with pressure ulcers
7.5 %
12.58 %
Percent of long-stay residents who lose too much weight
9.7 %
11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
39.5 %
44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
5.5 %
15.63 %
Percent of long-stay residents with a urinary tract infection
12.7 %
13.46 %
Percent of long-stay residents who have depressive symptoms 9.4 / 10.4 % 
Percent of long-stay residents who were physically restrained
3 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
20.6 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
72.5 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
63.5 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
3.5 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
1.50 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
25.8 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
0.4 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
9.5 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
6.2 %
9.22 %
Percent of long-stay residents who lose too much weight 5.6:1 % 
Percent of long-stay low-risk residents who lose control of their bowels or bladder
42.1 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
5 %
10.65 %
Percent of long-stay residents with a urinary tract infection
11.1 %
9.58 %
Percent of long-stay residents who have depressive symptoms 7.9:1 % 
Percent of long-stay residents who were physically restrained
2.4 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
1.9 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
16.6 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
56.6 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
54.6 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication 11.6:1 % 

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