Heartland Country Village - Black Earth Nursing Home
General Information
UPDATEFederal Provider Number
525521
Provider Name
HEARTLAND COUNTRY VILLAGE
Provider Address
634 CENTER ST
BLACK EARTH, WI 53515
BLACK EARTH, WI 53515
Provider Phone Number
6087672572
Provider SSA County
120
Provider County Name
Dane
Ownership Type
Non profit - Corporation
Number of Certified Beds
50
Number of Residents in Certified Beds
39
Provider Type
Medicare and Medicaid
Provider Resides in Hospital
N
Legal Business Name
TROUSDALE FOUNDATION INC. BENCHMARK HEALTHCARE OF DANE COUNTY
Date First Approved to Provide Medicare and Medicaid services
1993-10-01
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
3
Health Inspection Rating Footnote
QM Rating
5
QM Rating Footnote
Staffing Rating
3
Staffing Rating Footnote
RN Staffing Rating
5
RN Staffing Rating Footnote
Reported Staffing Footnote
Physical Therapist Staffing Footnote
Reported CNA Staffing Hours per Resident per Day
2.13333
Reported LPN Staffing Hours per Resident per Day
0.52179
Reported RN Staffing Hours per Resident per Day
1.08205
Reported Licensed Staffing Hours per Resident per Day
1.60385
Reported Total Nurse Staffing Hours per Resident per Day
3.73717
Reported Physical Therapist Staffing Hours per Resident Per Day
0.03077
Expected CNA Staffing Hours per Resident per Day
2.65135
Expected LPN Staffing Hours per Resident per Day
0.63664
Expected RN Staffing Hours per Resident per Day
0.96011
Expected Total Nurse Staffing Hours per Resident per Day
4.24811
Adjusted CNA Staffing Hours per Resident per Day
1.97429
Adjusted LPN Staffing Hours per Resident per Day
0.68026
Adjusted RN Staffing Hours per Resident per Day
0.84210
Adjusted Total Nurse Staffing Hours per Resident per Day
3.54609
Cycle 1 Total Number of Health Deficiencies
5
Cycle 1 Number of Standard Health Deficiencies
5
Cycle 1 Number of Complaint Health Deficiencies
0
Cycle 1 Health Deficiency Score
36
Cycle 1 Standard Survey Health Date
2014-09-24
Cycle 1 Number of Health Revisits
1
Cycle 1 Health Revisit Score
0
Cycle 1 Total Health Score
36
Cycle 2 Total Number of Health Deficiencies
3
Cycle 2 Number of Standard Health Deficiencies
3
Cycle 2 Number of Complaint Health Deficiencies
0
Cycle 2 Health Deficiency Score
12
Cycle 2 Standard Health Survey Date
2013-07-18
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
10
Cycle 3 Number of Standard Health Deficiencies
3
Cycle 3 Number of Complaint Health Deficiencies
7
Cycle 3 Health Deficiency Score
64
Cycle 3 Standard Health Survey Date
2012-05-17
Cycle 3 Number of Health Revisits
1
Cycle 3 Health Revisit Score
0
Cycle 3 Total Health Score
64
Total Weighted Health Survey Score
32.66700
Number of Facility Reported Incidents
0
Number of Substantiated Complaints
3
Number of Fines
1
Total Amount of Fines in Dollars
10920
Number of Payment Denials
1
Total Number of Penalties
2
Location
Processing Date
2015-06-01
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