1. 2015 Nursing Home Survey and Enforcement Actions
Annual Inspections Complaint Investigations
Office of Health Assurance and Licensing
July 2016

2. Number of Health Surveys per CY
Data as of July 8, 2016

3. Number of Health Deficiencies per CY
Data as of July 8, 2016

4. Number of Deficiency Free Annual Surveys per CY
*The above graph represents facilities that have had no LSC, Health or Licensure deficiencies on their annual surveys.
Data as of July 8, 2016

5. Substandard Quality of Care
Data as of July 8, 2016

6. Immediate Jeopardy (Health and LSC)
Data as of July 8, 2016

7. Health Deficiencies Level G and Above
Data as of July 8, 2016

8. Informal Dispute Resolution (IDR) Number of Deficiencies Disputed
Data as of July 8, 2016

9. Informal Dispute Resolution (IDR) - CY 2015
401 IDR Deficiencies Disputed
211 Event IDs
Data as of July 8, 2016

10. Informal Dispute Resolution (IDR) Level 2- CY 2015
84 IDR Level 2 Deficiencies Disputed
50 Events
Data as of July 8, 2016

11. Informal Dispute Resolution (IIDR) CY 2012 - 2015
2013
2014
2015
Affirmed 23 17 29 30
Deleted 4 10 8
Revised 7 2 5
Withdrawn 5*
Total 34 48 43
*These IDRs were not conducted due to conflicts between the dispute resolution processes of CFR and
Data as of July 8, 2016

12. Facilities with Imposed Remedies
Data as of July 8, 2016

13. Imposed Remedy Summary CY 2011 - 2015
Remedy Description
2011
2012
2013
2014
2015
CMPs
126
124
139
137
146
Denial of Payment (Discretionary and Mandatory) 20 21 11 17 19
Directed In-Service 26 8 2
Termination 3
State Monitoring 1
Suspension of Payments
Data as of July 8, 2016

14. Top Ten 2015 Health Deficiencies - Nursing Homes
F323 - Accidents & supervision (305)
F309 - Quality of care (266)
F441 - Infection control (235)
F329 - Unnecessary drugs (229)
F371 - Sanitary conditions, food prep & service (212)
F225 - Investigate/report allegations (151)
F226 - Develop/implement abuse & neglect policies (151)
F157 - Notify of changes (Injury/decline/room) (145)
F514 - Resident records complete/accurate/accessible (137)
F279 - Develop comprehensive care plans (136)
Data as of July 8, 2016

15. Top Ten 2015 Life Safety Code Deficiencies - Nursing Homes
K144 - Inspect, test and maintain generators (238)
K038 - Exits readily accessible at all times (213)
K062 - Automatic sprinkler systems are operable (195)
K052 - Fire alarm system (186)
K050 - Fire drills (178)
K147 - Management of electrical equipment (144)
K056 - Automatic sprinkler exist and installed properly (133)
K018 - Corridor doors (131)
K029 - Hazardous areas (129)
K025 - Smoke barriers (110)
Data as of July 8, 2016