Contract Nursing Home Exclusion Review

Part of the initial review for contracting and part of the annual review.

Name of Nursing Home LAUREL BAYE HEALTHCARE OF WILLISTON LLC
Address 5721 SPRINGFIELD HWY
WILLISTON SC, 29853
Telephone
Six Digit Provider Number 425297

A. Deficiencies

Rating (G-L) Program Requirements Corrected Date Current Survey Date
J Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. 02/16/2018 01/19/2018
J Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. 02/16/2018 01/19/2018
J Provide safe and appropriate respiratory care for a resident when needed. 02/16/2018 01/19/2018
J Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 02/16/2018 01/19/2018
J Ensure services provided by the nursing facility meet professional standards of quality. 02/16/2018 01/19/2018
J Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 02/16/2018 01/19/2018
Deficiency Count: 6
Section Rating: FAIL

*Facility fails if there are three level "G" or worse deficiencies in the current survey.

B. Health Requirement Deficiencies

Current Number at Facility State Average
Total Health Requirement Deficiencies: 13 6.7
Section Rating: PASS

Health Requirement Deficiencies: (The total number of health requirements deficiencies cannot be more than twice the State average in the current survey.)

C. RN Hours

RN Hours Current Average at Facility State Average
RN Hours per Resident Day: 0.20 0.75
Section Rating: FAIL

* Program requirement: Fail if less than state average

D. Total Nursing Staff

Total Nursing Staff Current Average at Facility State Average
Total Nursing Staff Hours per resident Day: 3.1 4.15
Section Rating: FAIL

* Program requirement: Fail if less than state average

E. Quality Measures

NOTE:

Although the Centers for Medicare and Medicaid Services (CMS) has released 24 Quality Measures, current VHA guidelines indicate that the following 18 Quality Measures be used to determine Pass/Fail for Section G of the review.

Quality Measures Facility Percent State Average Flagged
Percentage of high risk long-stay residents with pressure ulcers 0% 5.4%
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 0% 77.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 0% 78.2%
Percentage of long-stay residents experiencing one or more falls with major injury 0% 2.6%
Percentage of long-stay residents who have depressive symptoms 0% 0.9%
Percentage of long-stay residents who lose too much weight 0% 7.3%
Percentage of long-stay residents who received an antipsychotic medication 0% 11.4%
Percentage of long-stay residents who self-report moderate to severe pain 0% 3.9%
Percentage of long-stay residents who were physically restrained 0% 1%
Percentage of long-stay residents whose need for help with daily activities has increased 0% 11.6%
Percentage of long-stay residents with a catheter inserted and left in their bladder 0% 1.2%
Percentage of long-stay residents with a urinary tract infection 0% 4%

* A facility fails when six or more of the CMS Quality Measures listed below in Nursing Home Compare fall above the state average.
N.A.= contact home, data not submitted N.S. = contact home, numbers too small