Maple Leaf Health Care - Statesville Nursing Home
General Information
UPDATEFederal Provider Number
345340
Provider Name
MAPLE LEAF HEALTH CARE
Provider Address
2640 DAVIE AVENUE
STATESVILLE, NC 28625
STATESVILLE, NC 28625
Provider Phone Number
(704) 871-0705
Provider SSA County
480
Provider County Name
Iredell
Provider Website
Provider Description
Ownership Type
For profit - Corporation
Number of Certified Beds
94
Number of Residents in Certified Beds
89
Provider Type
Medicare and Medicaid
Provider Resides in Hospital
N
Legal Business Name
SSC STATESVILLE MAPLE LEAF OPERATING COMPANY LLC
Date First Approved to Provide Medicare and Medicaid services
1990-11-13
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
2
Overall Rating Footnote
Health Inspection Rating
2
Health Inspection Rating Footnote
QM Rating
3
QM Rating Footnote
Staffing Rating
3
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
2.54270
Reported LPN Staffing Hours per Resident per Day
0.40618
Reported RN Staffing Hours per Resident per Day
0.74551
Reported Licensed Staffing Hours per Resident per Day
1.15169
Reported Total Nurse Staffing Hours per Resident per Day
3.69439
Reported Physical Therapist Staffing Hours per Resident Per Day
0.09270
Expected CNA Staffing Hours per Resident per Day
2.62206
Expected LPN Staffing Hours per Resident per Day
0.64085
Expected RN Staffing Hours per Resident per Day
1.11083
Expected Total Nurse Staffing Hours per Resident per Day
4.37374
Adjusted CNA Staffing Hours per Resident per Day
2.37944
Adjusted LPN Staffing Hours per Resident per Day
0.52607
Adjusted RN Staffing Hours per Resident per Day
0.50147
Adjusted Total Nurse Staffing Hours per Resident per Day
3.40480
Cycle 1 Total Number of Health Deficiencies
4
Cycle 1 Number of Standard Health Deficiencies
4
Cycle 1 Number of Complaint Health Deficiencies
0
Cycle 1 Health Deficiency Score
24
Cycle 1 Standard Survey Health Date
2015-03-20
Cycle 1 Number of Health Revisits
1
Cycle 1 Health Revisit Score
0
Cycle 1 Total Health Score
24
Cycle 2 Total Number of Health Deficiencies
10
Cycle 2 Number of Standard Health Deficiencies
10
Cycle 2 Number of Complaint Health Deficiencies
0
Cycle 2 Health Deficiency Score
36
Cycle 2 Standard Health Survey Date
2013-11-07
Cycle 2 Number of Health Revisits
1
Cycle 2 Health Revisit Score
0
Cycle 2 Total Health Score
36
Cycle 3 Total Number of Health Deficiencies
5
Cycle 3 Number of Standard Health Deficiencies
5
Cycle 3 Number of Complaint Health Deficiencies
0
Cycle 3 Health Deficiency Score
24
Cycle 3 Standard Health Survey Date
2012-09-20
Cycle 3 Number of Health Revisits
1
Cycle 3 Health Revisit Score
0
Cycle 3 Total Health Score
24
Total Weighted Health Survey Score
28.00000
Number of Facility Reported Incidents
0
Number of Substantiated Complaints
0
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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