Country Club Ret Center I I I - Ashtabula Nursing Home
General Information
UPDATEFederal Provider Number
365642
Provider Name
COUNTRY CLUB RET CENTER I I I
Provider Address
925 E 26TH ST
ASHTABULA, OH 44004
ASHTABULA, OH 44004
Provider Phone Number
(440) 992-0022
Provider SSA County
30
Provider County Name
Ashtabula
Provider Website
Provider Description
Ownership Type
For profit - Partnership
Number of Certified Beds
65
Number of Residents in Certified Beds
53
Provider Type
Medicare and Medicaid
Provider Resides in Hospital
N
Legal Business Name
COUNTRY CLUB RETIREMENT CENTER LLC
Date First Approved to Provide Medicare and Medicaid services
1984-12-13
Continuing Care Retirement Community
N
Special Focus Facility
N
Provider Changed Ownership in Last 12 Months
N
With a Resident and Family Council
Resident
Automatic Sprinkler Systems in All Required Areas
Yes
Rating Detail Information
Overall Rating
4
Overall Rating Footnote
Health Inspection Rating
4
Health Inspection Rating Footnote
QM Rating
3
QM Rating Footnote
Staffing Rating
2
Staffing Rating Footnote
RN Staffing Rating
2
RN Staffing Rating Footnote
Reported Staffing Footnote
Physical Therapist Staffing Footnote
Reported CNA Staffing Hours per Resident per Day
2.61226
Reported LPN Staffing Hours per Resident per Day
0.94434
Reported RN Staffing Hours per Resident per Day
0.52547
Reported Licensed Staffing Hours per Resident per Day
1.46981
Reported Total Nurse Staffing Hours per Resident per Day
4.08207
Reported Physical Therapist Staffing Hours per Resident Per Day
0.02170
Expected CNA Staffing Hours per Resident per Day
2.45278
Expected LPN Staffing Hours per Resident per Day
0.74411
Expected RN Staffing Hours per Resident per Day
1.38642
Expected Total Nurse Staffing Hours per Resident per Day
4.58330
Adjusted CNA Staffing Hours per Resident per Day
2.61324
Adjusted LPN Staffing Hours per Resident per Day
1.05335
Adjusted RN Staffing Hours per Resident per Day
0.28320
Adjusted Total Nurse Staffing Hours per Resident per Day
3.59008
Cycle 1 Total Number of Health Deficiencies
0
Cycle 1 Number of Standard Health Deficiencies
0
Cycle 1 Number of Complaint Health Deficiencies
0
Cycle 1 Health Deficiency Score
0
Cycle 1 Standard Survey Health Date
2014-03-20
Cycle 1 Number of Health Revisits
0
Cycle 1 Health Revisit Score
0
Cycle 1 Total Health Score
0
Cycle 2 Total Number of Health Deficiencies
5
Cycle 2 Number of Standard Health Deficiencies
5
Cycle 2 Number of Complaint Health Deficiencies
0
Cycle 2 Health Deficiency Score
44
Cycle 2 Standard Health Survey Date
2013-01-07
Cycle 2 Number of Health Revisits
1
Cycle 2 Health Revisit Score
0
Cycle 2 Total Health Score
44
Cycle 3 Total Number of Health Deficiencies
3
Cycle 3 Number of Standard Health Deficiencies
2
Cycle 3 Number of Complaint Health Deficiencies
1
Cycle 3 Health Deficiency Score
12
Cycle 3 Standard Health Survey Date
2011-09-08
Cycle 3 Number of Health Revisits
1
Cycle 3 Health Revisit Score
0
Cycle 3 Total Health Score
12
Total Weighted Health Survey Score
16.66700
Number of Facility Reported Incidents
1
Number of Substantiated Complaints
0
Number of Fines
1
Total Amount of Fines in Dollars
64935
Number of Payment Denials
0
Total Number of Penalties
1
Location
Processing Date
2015-06-01
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