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COLONIAL HILLS NURSING CENTER

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COLONIAL HILLS NURSING CENTER VS
Nursing Homes USA
General
City MARYVILLE   0.1% Nursing Homes USA have MARYVILLE
State attribute explanation TN   2.1% Nursing Homes USA have TN
Street 2034 COCHRAN RD  
Zip Code 37803  
Phone 8659826161  
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
203 
108.94
Total Number of Residents
166 
91.25
Percent of Occupied Beds
82 %
83.65 %
Health Survey Date 10/5/2011  
Fire Survey Date 10/4/2011  
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 - Corporation  56.7% Nursing Homes USA have For profit - Corporation
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 Both  29.8% Nursing Homes USA have Both
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? No  68.7% Nursing Homes USA don't 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
26 
7.48
Staff Information
Number of Residents
166 
91.38
Number of RN Hours Per Resident Per Day
0.52 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.97 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.49 
1.59
Number of CNA Hours Per Resident Per Day
0.22 
5.49
Number Therapy Hours Per Resident Per Day
0.22 
0.10
Environmental Deficiencies
Deficiency #1 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: 06/17/2011
date Of Correction: 07/15/2011 
Mistreatment Deficiencies
Deficiency #1 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: 09/28/2011
date Of Correction: 10/14/2011 
Deficiency #2 Scope: Few
level Of Harm: 4
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 08/19/2011
date Of Correction: 09/09/2011 
Deficiency #3 Scope: Few
level Of Harm: 4
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: 08/19/2011
date Of Correction: 09/09/2011 
Deficiency #4 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: 08/19/2011
date Of Correction: 09/09/2011 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 04/21/2010
date Of Correction: 05/21/2010 
Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 4
deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.
survey Date: 08/19/2011
date Of Correction: 09/09/2011 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Reasonably Accommodate The Needs And Preferences Of Each Resident.
survey Date: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #3 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: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Try To Resolve Each Resident's Complaints Quickly.
survey Date: 04/21/2010
date Of Correction: 05/21/2010 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Follow Policies And Procedures To Convey The Resident's Personal Funds To The Appropriate Party Responsible After The Resident's Death.
survey Date: 06/10/2009
date Of Correction: 07/03/2009 
Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.
survey Date: 10/05/2011
date Of Correction: 11/04/2011 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Give Each Resident Enough Fluids To Keep Them Healthy And Prevent Dehydration.
survey Date: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #3 Scope: Some
level Of Harm: 4
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #4 Scope: Some
level Of Harm: 4
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 06/17/2011
date Of Correction: 07/15/2011 
Resident Assessment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Develop A Post-discharge Plan With The Resident And Family For The Resident's Care After Leaving The Nursing Home.
survey Date: 10/05/2011
date Of Correction: 11/04/2011 
Deficiency #2 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: 06/17/2011
date Of Correction: 07/15/2011 
Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 4
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 08/19/2011
date Of Correction: 09/09/2011 
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: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Give Or Get Quality Lab Services/tests In A Timely Manner To Meet The Needs Of Residents.
survey Date: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #4 Scope: Some
level Of Harm: 4
deficiency: Choose A Doctor To Serve As The Medical Director To Create Resident Care Policies And Coordinate Medical Care In The Facility.
survey Date: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #5 Scope: Some
level Of Harm: 4
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 04/21/2010
date Of Correction: 05/21/2010 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.
survey Date: 09/28/2011
date Of Correction: 10/14/2011 
Deficiency #2 Scope: Some
level Of Harm: 4
deficiency: At Least Once A Month, Have A Licensed Pharmacist Review Each Resident's Medication(s) And Report Any Irregularities To The Attending Doctor.
survey Date: 06/17/2011
date Of Correction: 07/15/2011 
Deficiency #3 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: 06/17/2011
date Of Correction: 07/15/2011 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
37.6 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
1.1 %
32.95 %
Percent of long-stay high-risk residents with pressure ulcers
8.2 %
12.58 %
Percent of long-stay residents who lose too much weight 12.3:1 % 
Percent of long-stay residents who have had a catheter inserted and left in their bladder
1.9 %
15.63 %
Percent of long-stay residents with a urinary tract infection
14.3 %
13.46 %
Percent of long-stay residents who have depressive symptoms
4.8 %
28.38 %
Percent of long-stay residents who were physically restrained
2.5 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
10.4 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
89.7 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
90.1 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
4.8 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
2.5 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
40.5 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
1.7 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
2.9 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers 8.9 / 9.9 % 
Percent of long-stay residents who lose too much weight
17.2 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
61 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.4 %
10.65 %
Percent of long-stay residents with a urinary tract infection
15.5 %
9.58 %
Percent of long-stay residents who have depressive symptoms
0.9 %
19.86 %
Percent of long-stay residents who were physically restrained
7.6 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
3 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
9.3 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
90.8 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
90.2 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
13.4 %
17.34 %

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