CARONDELET HOLY CROSS HOSPITAL - NOGALES, AZ

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CARONDELET HOLY CROSS HOSPITAL
1171 WEST TARGET RANGE ROAD
NOGALES, AZ 85621

RELIGIOUS NONMEDICAL HEALTH CARE INSTITUTIONS SNF/NF (DISTINCT PART)

Services provided by CARONDELET HOLY CROSS HOSPITAL:

Activities services are provided onsite to residents
Administration and storage of blood services are provided offsite to residents
Administration and storage of blood services are provided onsite to residents
Clinical laboratory services are provided offsite to residents
Clinical laboratory services are provided onsite to residents
Dental services are provided offsite to residents
Dietary services are provided onsite to non residents
Dietary services are provided onsite to residents
Housekeeping services are provided offsite to residents
Housekeeping services are provided onsite to residents
Mental health services are provided offsite to residents
Nursing services are provided onsite to non residents
Nursing services are provided onsite to residents
Occupational therapy services are provided offsite to residents
Occupational therapy services are provided onsite to residents
Field 1 - Indicates other activity services provided by staff onsite to residents
Pharmacy services are provided onsite to residents
Physical therapy services are provided offsite to residents
Physical therapy services are provided onsite to residents
Physician services are provided offsite to residents
Physician services are provided onsite to residents
Podiatry services are provided offsite to residents
Social work services are provided onsite to non residents
Social work services are provided onsite to residents
Speech/language pathology services are provided offsite to residents
Speech/language pathology services are provided onsite to residents
Diagnostic xray services are provided offsite to residents
Diagnostic xray services are provided onsite to residents

Beds - Total (Total number of beds in a facility, including those in non-Participating or non-licensed areas): 49

Beds - Total certified (Number of beds in Medicare and/or Medicaid certified areas within a facility): 49

Beds - Nursing facility (Number of Medicaid certified skilled nursing care beds in a facility): 41

Lpn/lvn - Full time (The number of full-time equivalent licensed practical/ vocational nurses employed by a facility on a full time basis): 3.21

Registered nurse - Full time (The number of full-time equivalent registered nurses employed by a facility on a full time basis): 2.14

Program participation (Indicates if the provider participates in Medicare, Medicaid, or both programs): MEDICARE AND MEDICAID

Related provider number (This field is used when a provider's facility contains more than one distinct provider,such as a hospital with distinct part long term care. the number in this field will be the provider nmbr of the highest level of care): 030040

Activity professional - Full time (The number of full-time equivalent activities professionals employed full time by a facility): 1.07

Administrator - Full time (The number of full-time equivalent administrative staff employed on a full time basis by a facility): 1.14

Beds - Snf/nf (Number of beds certified for both Medicare and Medicaid skilled nursing care in a long term care facility): 8

Cert nurse aides - Full time (The number of full-time equivalent certified nurse aides employed by a facility on a full time basis): 18.21

Cert nurse aides - Part time (The number of full-time equivalent certified nurse aides employed by a facility on a part time basis): 3.64

Dietitians - Full time (The number of full-time equivalent dietitians employed by a facility on a full time basis): 0.34

Food service - Full time (The number of full-time equivalent food service personnel employed by a facility on a full time basis): 3.21

Housekeeping - Full time (The number of full-time equivalent housekeeping personnel employed by a facility on a full time basis): 2.63

Lpn/lvn - Part time (The number of full-time equivalent licensed practical/ vocational nurses employed by a facility on a part time basis): 0.64

Medical director - Part time (The number of full-time equivalent medical directors employed by a facility on a part time basis): 0.14

Multi-Facility organization name (The name of the multi-Facility organization that owns the facility): CARONDELET HEALTH NETWORK

Multi-Facility organization owned (Indicates if a facility is owned by an organization that owns (or leases) two or more nursing facilities): Yes

Nurses with admin duties-Part time (Number of full-time equivalent nurses with administrative duties employed by a facility on a part time basis): 0.69

Occupational therapist - Part time (The number of full-time equivalent occupational therapists employed by a facility on a part time basis): 0.34

Organized family group (Indicates if the facility has an organized group of family members of residents): Yes

Organized resident group (Indicates if the facility has an organized residents group): Yes

Other activities staff-Part time (Number of part time staff hours provided by other activ ities staff): 0.36

Pharmacists - Full time (The number of full-time equivalent pharmacists employed by a facility on a full time basis): 0.46

Physical therapists - Part time (The number of full-time equivalent physical therapists employed by a facility on a part time basis): 0.16

Provider based facility (Indicates if a long term care facility is provider based): Yes

Registered nurse - Part time (The number of full-time equivalent registered nurses employed by a facility on a part time basis): 2.29

Rn director of nursing - Full time (The number of full-time equivalent rn director of nursing employed by a facility on a full time basis): 1.14

Social worker - Full time (The number of full-time equivalent social workers employed by a facility on a full time basis): 0.50

Special care beds-Spec rehab (The number of beds in a unit identified and dedicated by the facility for residents with specialized rehab needs): 8

Speech pathologist - Part time (The number of full-time equivalent speech pathologists employed by a facility on a part time basis): 0.04

Compliance: plan of correction (Indicates if a provider is in compliance with program requirements based on an acceptable plan for correction of deficiencies): COMPLIANCE BASED ON ACCEPTABLE POC

Compliance: status (Indicates if a provider or supplier is in compliance with program requirements): IN COMPLIANCE

Current survey date (The date of the health or life safety code survey, whichever is later. the "official" survey date for the provider): Mar 2002

Eligibility code (Indicates if a facility is eligible to participate in the Medicare and/or Medicaid programs): ELIGIBLE TO PARTICIPATE

Participation date (The date a facility is first approved to provide Medicare and/or Medicaid services): Sep 1988

Quality Measure Score

	Here	State Average	Nation Average
Heart Attack Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)	100%	83%	85%
Heart Attack Patients Given Aspirin at Arrival	100%	95%	93%
Heart Attack Patients Given Aspirin at Discharge	100%	89%	90%
Heart Attack Patients Given Beta Blocker at Arrival	100%	89%	88%
Heart Attack Patients Given Beta Blocker at Discharge	100%	91%	91%

	Here	State Average	Nation Average
Heart Failure Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)	67%	84%	84%
Heart Failure Patients Given Discharge Instructions	33%	49%	66%
Heart Failure Patients Given an Evaluation of Left Ventricular Systolic (LVS) Function	20%	84%	85%

	Here	State Average	Nation Average
Pneumonia Patients Assessed and Given Influenza Vaccination	38%	70%	75%
Pneumonia Patients Assessed and Given Pneumococcal Vaccination	38%	73%	75%
Pneumonia Patients Given Initial Antibiotic(s) within 6 Hours After Arrival	70%	91%	93%
Pneumonia Patients Given Oxygenation Assessment	100%	99%	99%
Pneumonia Patients Given Smoking Cessation Advice/Counseling	100%	76%	84%
Pneumonia Patients Given the Most Appropriate Initial Antibiotic(s)	97%	89%	86%
Pneumonia Patients Whose Initial Emergency Room Blood Culture Was Performed Prior To The Administration Of The First Hospital Dose Of Antibiotics	75%	87%	90%

	Here	State Average	Nation Average
Surgery Patients Who Received Preventative Antibiotic(s) One Hour Before Incision	75%	78%	82%
Surgery Patients Who Received Treatment To Prevent Blood Clots Within 24 Hours Before or After Selected Surgeries to Prevent Blood Clots	91%	72%	75%
Surgery Patients Who Received the Appropriate Preventative Antibiotic(s) for Their Surgery	93%	90%	90%
Surgery Patients Whose Doctors Ordered Treatments to Prevent Blood Clots (Venous Thromboembolism) For Certain Types of Surgeries	94%	77%	79%
Surgery Patients Whose Preventative Antibiotic(s) are Stopped Within 24 hours After Surgery	98%	75%	78%

Hospital Consumer Assessment of Healthcare Providers & Systems Survey

How do patients rate the hospital overall?

	Here	State Average	Nation Average
Patients who gave a rating of 9 or 10 (high)	45%	63%	63
Patients who gave a rating of 7 or 8 (medium)	32%	25%	26
Patients who gave a rating of 6 or lower (low)	23%	12%	11

How often did doctors communicate well with patients?

	Here	State Average	Nation Average
Doctors always communicated well	75%	75%	79
Doctors usually communicated well	19%	18%	16
Doctors sometimes or never communicated well	6%	7%	5

How often did nurses communicate well with patients?

	Here	State Average	Nation Average
Nurses always communicated well	66%	71%	73
Nurses usually communicated well	25%	22%	21
Nurses sometimes or never communicated well	9%	7%	6

How often did patients receive help quickly from hospital staff?

	Here	State Average	Nation Average
Patients always received help as soon as they wanted	55%	59%	60
Patients usually received help as soon as they wanted	31%	29%	28
Patients sometimes or never received help as soon as they wanted	14%	12%	12

How often did staff explain about medicines before giving them to patients?

	Here	State Average	Nation Average
Staff always explained	52%	56%	58
Staff usually explained	23%	19%	18
Staff sometimes or never explained	25%	25%	24

How often was patients' pain well controlled?

	Here	State Average	Nation Average
Pain was always well controlled	63%	67%	67
Pain was usually well controlled	30%	25%	25
Pain was sometimes or never well controlled	7%	8%	8

How often was the area around patients' rooms kept quiet at night?

	Here	State Average	Nation Average
Always quiet at night	46%	50%	54
Usually quiet at night	34%	33%	32
Sometimes or never quiet at night	20%	17%	14

How often were the patients' rooms and bathrooms kept clean?

	Here	State Average	Nation Average
Room was always clean	63%	66%	68
Room was usually clean	20%	22%	21
Room was sometimes or never clean	17%	12%	11

Were patients given information about what to do during their recovery at home?

	Here	State Average	Nation Average
Yes, staff did give patients this information	72%	77%	79
No, staff did not give patients this information	28%	23%	21

Would patients recommend the hospital to friends and family?

	Here	State Average	Nation Average
YES, patients would definitely recommend the hospital	46%	67%	67
YES, patients would probably recommend the hospital	39%	26%	27
NO, patients would not recommend the hospital (they probably would not or definitely would not recommend it)	15%	7%	6

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