IREDELL MEMORIAL HOSPITAL INC

Nursing Home Inspector

557 BROOKDALE DRIVE
STATESVILLE, NC 28677
Iredell County
Phone: 704-878-4541
Provider Number: 345306
Last Inspection: 01/19/2017

About the Nursing Home

Number of Beds: 48
Number of Residents: 20
Beds Available: 28
Percent Occupancy: 42%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Government - Hospital district
Within Hospital?: YES

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

9

Facility
25

County
14

NC
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

9

2017
11

2015
3

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

1/19/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 2/10/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 2/10/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 2/10/2017
 

12/30/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 1/19/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 1/19/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 1/19/2016
 

3/18/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 3/25/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

4/20/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Immediate 5 5/10/2016
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Immediate 5 5/10/2016
 
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Immediate 5 5/10/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Immediate 5 5/10/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Immediate 5 5/10/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Immediate 5 5/10/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Immediate 5 5/10/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NC State Avg
Number of Residents 20 82.17 84.96
Registered Nurses 3.74 1.15 0.72
Licensed Practical / Vocational Nurses 1.29 0.84 0.87
Certified Nursing Assistants 3.55 2.32 2.33
Total Staff Hours 8.57 4.31 3.91

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NC State Avg%
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 7 7
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 95 93
of long-stay residents experiencing one or more falls with major injury 9 96 93
of long-stay residents who have depressive symptoms 0 4 3
of long-stay residents who lose too much weight 14 1 2
of long-stay residents who received an antianxiety or hypnotic medication 36 8 8
of long-stay residents who received an antipsychotic medication 18 33 29
of long-stay residents who were physically restrained 0 14 13
of long-stay residents whose need for help with daily activities has increased 30 4 6
of long-stay residents with a catheter inserted and left in their bladder 4 0 0
of long-stay residents with a urinary tract infection 19 26 23
of short-stay residents assessed and appropriately given the pneumococcal vaccine 99 17 18
of short-stay residents who had an outpatient emergency department visit 8 2 1
of short-stay residents who made improvements in function 64 6 4
of short-stay residents who newly received an antipsychotic medication 1 60 55
of short-stay residents who self-report moderate to severe pain 10 87 83
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 97 11 13
of short-stay residents who were rehospitalized after a nursing home admission 14 66 64
of short-stay residents who were successfully discharged to the community 77 1 1
of short-stay residents with pressure ulcers that are new or worsened 1 10 14