Pine Haven Christian Home - Sheboygan Falls Nursing Home
General Information
UPDATEFederal Provider Number
525676
Provider Name
PINE HAVEN CHRISTIAN HOME
Provider Address
531 GIDDINGS AVE
SHEBOYGAN FALLS, WI 53085
SHEBOYGAN FALLS, WI 53085
Provider Phone Number
9204672401
Provider SSA County
580
Provider County Name
Sheboygan
Ownership Type
Non profit - Corporation
Number of Certified Beds
50
Number of Residents in Certified Beds
45
Provider Type
Medicare and Medicaid
Provider Resides in Hospital
N
Legal Business Name
PINE HAVEN CHRISTIAN HOME INC
Date First Approved to Provide Medicare and Medicaid services
2004-03-05
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
5
Overall Rating Footnote
Health Inspection Rating
4
Health Inspection Rating Footnote
QM Rating
5
QM Rating Footnote
Staffing Rating
5
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
3.03556
Reported LPN Staffing Hours per Resident per Day
0.59667
Reported RN Staffing Hours per Resident per Day
1.30000
Reported Licensed Staffing Hours per Resident per Day
1.89667
Reported Total Nurse Staffing Hours per Resident per Day
4.93223
Reported Physical Therapist Staffing Hours per Resident Per Day
0.00000
Expected CNA Staffing Hours per Resident per Day
2.83531
Expected LPN Staffing Hours per Resident per Day
0.64526
Expected RN Staffing Hours per Resident per Day
0.95931
Expected Total Nurse Staffing Hours per Resident per Day
4.43988
Adjusted CNA Staffing Hours per Resident per Day
2.62700
Adjusted LPN Staffing Hours per Resident per Day
0.76750
Adjusted RN Staffing Hours per Resident per Day
1.01256
Adjusted Total Nurse Staffing Hours per Resident per Day
4.47789
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
20
Cycle 1 Standard Survey Health Date
2014-10-16
Cycle 1 Number of Health Revisits
1
Cycle 1 Health Revisit Score
0
Cycle 1 Total Health Score
20
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
28
Cycle 2 Standard Health Survey Date
2013-10-02
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
10
Cycle 3 Number of Complaint Health Deficiencies
0
Cycle 3 Health Deficiency Score
60
Cycle 3 Standard Health Survey Date
2012-08-23
Cycle 3 Number of Health Revisits
1
Cycle 3 Health Revisit Score
0
Cycle 3 Total Health Score
60
Total Weighted Health Survey Score
29.33300
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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