Country Villa Hacienda Healthcare - San Bernardino Nursing Home
General Information
UPDATEFederal Provider Number
56053
Provider Name
COUNTRY VILLA HACIENDA HEALTHCARE
Provider Address
1311 EAST DATE STREET
SAN BERNARDINO, CA 92404
SAN BERNARDINO, CA 92404
Provider Phone Number
(909) 882-3316
Provider SSA County
460
Provider County Name
San Bernardino
Provider Website
Provider Description
Ownership Type
For profit - Corporation
Number of Certified Beds
99
Number of Residents in Certified Beds
94
Provider Type
Medicare and Medicaid
Provider Resides in Hospital
N
Legal Business Name
MOUNTAINSIDE OPERATING COMPANY, LLC
Date First Approved to Provide Medicare and Medicaid services
1970-06-01
Continuing Care Retirement Community
N
Special Focus Facility
N
Provider Changed Ownership in Last 12 Months
N
With a Resident and Family Council
Both
Automatic Sprinkler Systems in All Required Areas
Yes
Rating Detail Information
Overall Rating
5
Overall Rating Footnote
Health Inspection Rating
3
Health Inspection Rating Footnote
QM Rating
5
QM Rating Footnote
Staffing Rating
4
Staffing Rating Footnote
RN Staffing Rating
3
RN Staffing Rating Footnote
Reported Staffing Footnote
Physical Therapist Staffing Footnote
Reported CNA Staffing Hours per Resident per Day
2.49255
Reported LPN Staffing Hours per Resident per Day
0.99255
Reported RN Staffing Hours per Resident per Day
0.55372
Reported Licensed Staffing Hours per Resident per Day
1.54628
Reported Total Nurse Staffing Hours per Resident per Day
4.03882
Reported Physical Therapist Staffing Hours per Resident Per Day
0.06543
Expected CNA Staffing Hours per Resident per Day
2.24756
Expected LPN Staffing Hours per Resident per Day
0.59099
Expected RN Staffing Hours per Resident per Day
0.92302
Expected Total Nurse Staffing Hours per Resident per Day
3.76156
Adjusted CNA Staffing Hours per Resident per Day
2.72116
Adjusted LPN Staffing Hours per Resident per Day
1.39397
Adjusted RN Staffing Hours per Resident per Day
0.44824
Adjusted Total Nurse Staffing Hours per Resident per Day
4.32801
Cycle 1 Total Number of Health Deficiencies
7
Cycle 1 Number of Standard Health Deficiencies
5
Cycle 1 Number of Complaint Health Deficiencies
2
Cycle 1 Health Deficiency Score
64
Cycle 1 Standard Survey Health Date
2014-09-19
Cycle 1 Number of Health Revisits
1
Cycle 1 Health Revisit Score
0
Cycle 1 Total Health Score
64
Cycle 2 Total Number of Health Deficiencies
11
Cycle 2 Number of Standard Health Deficiencies
9
Cycle 2 Number of Complaint Health Deficiencies
2
Cycle 2 Health Deficiency Score
56
Cycle 2 Standard Health Survey Date
2013-11-22
Cycle 2 Number of Health Revisits
1
Cycle 2 Health Revisit Score
0
Cycle 2 Total Health Score
56
Cycle 3 Total Number of Health Deficiencies
12
Cycle 3 Number of Standard Health Deficiencies
10
Cycle 3 Number of Complaint Health Deficiencies
2
Cycle 3 Health Deficiency Score
48
Cycle 3 Standard Health Survey Date
2012-12-10
Cycle 3 Number of Health Revisits
1
Cycle 3 Health Revisit Score
0
Cycle 3 Total Health Score
48
Total Weighted Health Survey Score
58.66700
Number of Facility Reported Incidents
4
Number of Substantiated Complaints
4
Number of Fines
0
Total Amount of Fines in Dollars
0
Number of Payment Denials
0
Total Number of Penalties
0
Location
Processing Date
2015-06-01
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