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ESPANOLA VALLEY NURSING & REHAB CENTER

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ESPANOLA VALLEY NURSING & REHAB CENTER VS
Nursing Homes USA
General
City ESPANOLA   0% Nursing Homes USA have ESPANOLA
State attribute explanation NM   0.5% Nursing Homes USA have NM
Street 720 HACIENDA STREET  
Zip Code 87532  
Phone 5057536769  
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
120 
108.94
Total Number of Residents
89 
91.25
Percent of Occupied Beds
74 %
83.65 %
Health Survey Date 6/24/2011  
Fire Survey Date 6/21/2011  
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 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
7.48
Staff Information
Number of Residents
89 
91.38
Number of RN Hours Per Resident Per Day
0.42 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.68 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.11 
1.59
Number of CNA Hours Per Resident Per Day
0.06 
5.49
Number Therapy Hours Per Resident Per Day
0.06 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 2
deficiency: Keep All Essential Equipment Working Safely.
survey Date: 02/07/2012
date Of Correction: 05/23/2012 
Deficiency #2 Scope: Many
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: 02/07/2012
date Of Correction: 05/23/2012 
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: 02/07/2012
date Of Correction: 05/23/2012 
Deficiency #2 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: 02/07/2012
date Of Correction: 05/23/2012 
Deficiency #3 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: 02/07/2012
date Of Correction: 05/23/2012 
Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 4
deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.
survey Date: 02/07/2012
date Of Correction: 05/23/2012 
Resident Assessment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Coordinate Assessments With The Pre-admission Screening And Resident Review Program For Mentally-ill And Mentally-retarded Patients.
survey Date: 02/07/2012
date Of Correction: 05/23/2012 
Deficiency #2 Scope: Few
level Of Harm: 4
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 02/07/2012
date Of Correction: 05/23/2012 
Administration Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 2
deficiency: 1) Receive Registry Verification That A Nurse Aide Has Met The Required Training And Skills That The State Requires; And 2) Ensure Nurse Aides Receive The Required Retraining After 24 Months If Nursing Related Services Were Not Provided For Monetary Compensation
survey Date: 02/07/2012
date Of Correction: 05/23/2012 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication 13.1:1 % 
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain 23.8:1 % 
Percent of long-stay high-risk residents with pressure ulcers
3.4 %
12.58 %
Percent of long-stay residents who lose too much weight
18.8 %
11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
29.3 %
44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
1.6 %
15.63 %
Percent of long-stay residents with a urinary tract infection
3.5 %
13.46 %
Percent of long-stay residents who have depressive symptoms
17.2 %
28.38 %
Percent of long-stay residents who were physically restrained 8.9 / 9.9 % 
Percent of short-stay residents who self-report moderate to severe pain
31.9 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
13.8 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
12.4-2413.6-24 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
3.7 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
4.4 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
13.2 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
21.4 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
1.8 %
9.22 %
Percent of long-stay residents who lose too much weight
19.2 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
34.5 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
2.20 %
10.65 %
Percent of long-stay residents with a urinary tract infection
5 %
9.58 %
Percent of long-stay residents who have depressive symptoms
14.8 %
19.86 %
Percent of long-stay residents who were physically restrained
8 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
3.2 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
37.7 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
8.8 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened 11.6:1 % 
Percent of short-stay residents who newly received an antipsychotic medication
8.5 %
17.34 %

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