Countryside Manor - Stokesdale Nursing Home

General Information

UPDATE
Federal Provider Number
345390
Provider Name
COUNTRYSIDE MANOR
Provider Address
7700 US 158 EAST
STOKESDALE, NC 27357
Provider Phone Number
3366436301
Provider SSA County
400
Provider County Name
Guilford
Ownership Type
For profit - Corporation
Number of Certified Beds
60
Number of Residents in Certified Beds
50
Provider Type
Medicare and Medicaid
Provider Resides in Hospital
N
Legal Business Name
COUNTRYSIDE MANOR, INC
Date First Approved to Provide Medicare and Medicaid services
1991-07-22
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
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
3.12500
Reported LPN Staffing Hours per Resident per Day
0.97900
Reported RN Staffing Hours per Resident per Day
0.63300
Reported Licensed Staffing Hours per Resident per Day
1.61200
Reported Total Nurse Staffing Hours per Resident per Day
4.73700
Reported Physical Therapist Staffing Hours per Resident Per Day
0.03400
Expected CNA Staffing Hours per Resident per Day
2.69269
Expected LPN Staffing Hours per Resident per Day
0.61718
Expected RN Staffing Hours per Resident per Day
0.95372
Expected Total Nurse Staffing Hours per Resident per Day
4.26360
Adjusted CNA Staffing Hours per Resident per Day
2.84764
Adjusted LPN Staffing Hours per Resident per Day
1.31658
Adjusted RN Staffing Hours per Resident per Day
0.49593
Adjusted Total Nurse Staffing Hours per Resident per Day
4.47846
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
2014-04-10
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
1
Cycle 2 Health Deficiency Score
20
Cycle 2 Standard Health Survey Date
2013-01-31
Cycle 2 Number of Health Revisits
1
Cycle 2 Health Revisit Score
0
Cycle 2 Total Health Score
0
Cycle 3 Total Number of Health Deficiencies
0
Cycle 3 Number of Standard Health Deficiencies
0
Cycle 3 Number of Complaint Health Deficiencies
0
Cycle 3 Health Deficiency Score
0
Cycle 3 Standard Health Survey Date
2012-02-29
Cycle 3 Number of Health Revisits
0
Cycle 3 Health Revisit Score
0
Cycle 3 Total Health Score
0
Total Weighted Health Survey Score
6.66700
Number of Facility Reported Incidents
0
Number of Substantiated Complaints
2
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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