Villa Mary Immaculate

Total Number of Beds: 160	Percent of Occupied Beds: 94%
Total Number of Residents: 150	Located Within a Hospital: No
Type of Ownership: Non profit - Church related	Multiple Nursing Homes by Same Owner: No
Councils the Nursing Home Participates in: Family & Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 11/10/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.73

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.77

Number of CNA Hours per Nursing Home Resident per Day: 2.25

Number of Staff Hours per Nursing Home Resident per Day: 3.75

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 24%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 13%
Percent of Short-Stay Residents With Delirium: 21%
** Details Last Reported on: 11/10/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-12-18	2002-02-21	Resident Rights Deficiencies	Try to resolve each resident's complaints quickly.	Pattern	Minimal harm or potential for actual harm
2001-12-18	2002-02-21	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
2001-12-18	2002-02-21	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2001-12-18	2002-02-21	Quality Care Deficiencies	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Pattern	Minimal harm or potential for actual harm
2001-12-18	2002-02-21	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
2001-12-18	2002-02-21	Quality Care Deficiencies	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
2001-12-18	2002-02-21	Resident Assessment Deficiencies	Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing.	Pattern	Minimal harm or potential for actual harm
2001-12-18	2002-02-21	Administration Deficiencies	1) Review the work of each nurse aide every year; or 2) give regular training for the nurse aides.	Pattern	Minimal harm or potential for actual harm
2002-12-20	2003-02-18	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
2002-12-20	2003-02-18	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Pattern	Minimal harm or potential for actual harm
2002-12-20	2003-02-18	Quality Care Deficiencies	Make sure that each resident gets help to keep vision and hearing.	Isolated	Minimal harm or potential for actual harm
2002-12-20	2003-02-18	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
2002-12-20	2003-02-18	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2002-12-20	2003-02-18	Quality Care Deficiencies	Give or get dental care for each resident.	Isolated	Minimal harm or potential for actual harm
2002-12-20	2003-02-18	Environmental Deficiencies	Provide bedrooms that don't allow residents to see each other when privacy is needed.	Pattern	Potential for minimal harm
2002-12-20	2003-02-18	Environmental Deficiencies	Make sure that a working call system is available in each resident's room or bathroom and bathing area.	Pattern	Minimal harm or potential for actual harm
2003-11-10	2004-01-09	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Pattern	Minimal harm or potential for actual harm
2003-11-10	2004-01-09	Quality Care Deficiencies	Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
2003-11-10	2004-01-09	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Pattern	Minimal harm or potential for actual harm
2003-11-10	2004-01-09	Quality Care Deficiencies	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Minimal harm or potential for actual harm
2003-11-10	2004-01-09	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
2003-11-10	2004-01-09	Environmental Deficiencies	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.