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WILLIAMSBURG VILLAGE HEALTHCARE CAMPUS

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WILLIAMSBURG VILLAGE HEALTHCARE CAMPUS VS
Nursing Homes USA
General
City DESOTO   0% Nursing Homes USA have DESOTO
State attribute explanation TX   7.6% Nursing Homes USA have TX
Street 941 SCOTLAND DR  
Zip Code 75115  
Phone 9725726200  
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
242 
108.94
Total Number of Residents
230 
91.25
Percent of Occupied Beds
95 %
83.65 %
Health Survey Date 5/25/2012  
Fire Survey Date 5/24/2012  
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 - 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
34 
7.48
Staff Information
Number of Residents
230 
91.38
Number of RN Hours Per Resident Per Day
0.41 
0.77
Number of LPN/LVN Hours Per Resident Per Day
1.25 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.66 
1.59
Number of CNA Hours Per Resident Per Day
0.05 
5.49
Number Therapy Hours Per Resident Per Day
0.05 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 11/15/2011
date Of Correction: 12/09/2011 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Provide Clean Bed And Bath Linens That Are In Good Condition.
survey Date: 08/12/2011
date Of Correction: 09/11/2011 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 04/21/2011
date Of Correction: 05/21/2011 
Deficiency #4 Scope: Many
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #5 Scope: Some
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Deficiency #6 Scope: Some
level Of Harm: 1
deficiency: Provide Housekeeping And Maintenance Services.
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Deficiency #7 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: 04/02/2009
date Of Correction: 04/27/2009 
Mistreatment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 12/16/2010
date Of Correction: 12/17/2010 
Deficiency #2 Scope: Some
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: 12/16/2010
date Of Correction: 12/17/2010 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 08/05/2010
date Of Correction: 09/09/2010 
Deficiency #4 Scope: Some
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: 08/05/2010
date Of Correction: 09/09/2010 
Deficiency #5 Scope: Some
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #6 Scope: Some
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: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 03/06/2010
date Of Correction: 04/30/2010 
Deficiency #8 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: 03/06/2010
date Of Correction: 04/30/2010 
Deficiency #9 Scope: Some
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Deficiency #10 Scope: Some
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 06/05/2009
date Of Correction: 06/29/2009 
Deficiency #11 Scope: Some
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: 06/05/2009
date Of Correction: 06/29/2009 
Resident Rights Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Try To Resolve Each Resident's Complaints Quickly.
survey Date: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #2 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: 03/10/2010
date Of Correction: 04/30/2010 
Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 03/31/2011
date Of Correction: 04/29/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: 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: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Develop Policies And Procedures For Influenza And Pneumococcal Immunizations.
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Administration Deficiencies
Deficiency #1 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: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: 1) Review The Work Of Each Nurse Aide Every Year; And 2) Give Regular In-service Training Based Upon These Reviews.
survey Date: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Deficiency #5 Scope: Some
level Of Harm: 1
deficiency: 1) Review The Work Of Each Nurse Aide Every Year; And 2) Give Regular In-service Training Based Upon These Reviews.
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Deficiency #6 Scope: Some
level Of Harm: 3
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Deficiency #7 Scope: Some
level Of Harm: 2
deficiency: Employ Qualified Full-time, Part-time Or Consultant Professionals That Must Be Licensed, Certified, Or Registered Staff To Give Needed Services.
survey Date: 06/05/2009
date Of Correction: 06/06/2009 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 03/10/2010
date Of Correction: 04/30/2010 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 08/28/2009
date Of Correction: 10/21/2009 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 06/05/2009
date Of Correction: 06/12/2009 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
36.1 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
2.4 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain
0.9 %
16.66 %
Percent of long-stay high-risk residents with pressure ulcers
8.7 %
12.58 %
Percent of long-stay residents who lose too much weight
11.5 %
11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
52.2 %
44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
2 %
15.63 %
Percent of long-stay residents with a urinary tract infection 8.6:1 % 
Percent of long-stay residents who have depressive symptoms
75.2 %
28.38 %
Percent of long-stay residents who were physically restrained
75.2 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain 11.6:1 % 
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
81.5 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
78.1 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
75.2 
45.90
Percent of long-stay residents experiencing one or more falls with major injury
1.7 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
34.6 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
2.1 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
3.2 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
9.5 %
9.22 %
Percent of long-stay residents who lose too much weight
8.2 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
51.9 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
2.8 %
10.65 %
Percent of long-stay residents with a urinary tract infection
9.8 %
9.58 %
Percent of long-stay residents who have depressive symptoms
0.5 - 2.0 %
19.86 %
Percent of long-stay residents who were physically restrained
75.2 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
1.8 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
16.4 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
78.9 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
76.2 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication 21.2:1 % 

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