T L C HEALTH NETWORK LAKE SHORE HOSP NURSING FAC (IRVING, NY) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	26.7%
New York:	15.6%

Percent of long-stay residents who self-report moderate to severe pain

Here:	16.3%
New York:	7.6%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	9.5%
New York:	8.4%

Percent of long-stay residents who lose too much weight

This Nursing Home:	9.6%
New York:	6.4%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	3.7%
New York:	3.1%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	12.0%
New York:	6.8%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	3.8%
New York:	12.6%

Percent of long-stay residents who were physically restrained

Here:	4.8%
New York:	2.3%

Percent of long-stay residents experiencing one or more falls with major injury

Here:	3.6%
State:	2.9%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	92.9%
New York:	96.7%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	100.0%
New York:	97.3%

Percent of short-stay residents who self-report moderate to severe pain

This Nursing Home:	28.6%
State:	16.9%

Percent of short-stay residents with Pressure ulcers that are new or worsened

This Nursing Home:	2.4%
State:	1.8%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	96.4%
New York:	86.9%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	97.7%
State:	85.0%

Percent of short-stay residents who newly received an antipsychotic medication

This Nursing Home:	1.7%
State:	3.1%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	11.0%
New York:	20.8%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.440
State:	0.637

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

This Nursing Home:	1.380
State:	0.790

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.820
New York:	1.425

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.100
New York:	0.080

Number Therapy Hours Per Resident Per Day

Here:	0.100
New York:	0.081

Complaint Deficiency

Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Some
No-smoking signs where oxygen is used
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridors that are separated from common areas by walls constructed to limit the passage of smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Other fire safety features required by fire safety codes
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide proof that all residents' personal money which is deposited with the nursing home, is secure
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow the resident the right to participate in the planning or revision of the resident's care plan
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that doctors visit residents regularly, as required
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give or get specialized rehabilitative services per the patient's assessment or plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide or obtain dental services for each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridors or aisles that are unobstructed and are at least 8 feet in width
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly constructed piped-in oxygen systems
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow the resident the right to participate in the planning or revision of the resident's care plan
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents receive proper treatment and assistive devices to maintain their vision and hearing
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day
- Harm: Potential for minimal harm
- Scope: Some
Provide or obtain dental services for each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few

T L C HEALTH NETWORK LAKE SHORE HOSP NURSING FAC - IRVING, NY

Quality Measures

Staff Information

Complaint Deficiency

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