General Information: BAPTIST LEAKE EXTENDED CARE FACILITY
Nursing home name BAPTIST LEAKE EXTENDED CARE FACILITY
Address310 ELLIS STREET
CARTHAGE, MS 39051
Phone number (601) 267-1355
Located within a hospital No
Type of ownership Non profit - Other
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicaid
Continue Care Retirement CommunityNo
Resident and family councils Resident
Certified number of beds 44
Total number of residents 40
Perc of occupied beds 90
Sprinkler status Yes
Number of Facility Reported Incidents1
Number of Substantiated Complaints0
Number of Fines0
Total Amount of Fines$0
Total Number of Penalties0
Total Number of Penalties0
Ratings Summary: BAPTIST LEAKE EXTENDED CARE FACILITY
Overall rating 2
2
Nursing Home Staffing 3
3
Registered Nurses only 5
5
Health Inspections 2
2
Quality Measures 3
3
Nursing Home Staffing Info: BAPTIST LEAKE EXTENDED CARE FACILITY
National AverageMississippi AverageBAPTIST LEAKE EXTENDED CARE FACILITY
Overall staff rating NA NA 3
3
Registered Nurses only rating NANA 5
5
Total Number of Residents NA NA 40
Total Number of Nurse Staff Hours per Resident per Day 4.11 hours 4.22 hours 2.53 hours
Total Number of Licensed Nurse Staff Hours per Resident per Day 1.64 hours 1.79 hours 2.53 hours
Registered Nurses Hours per Residents per Day 0.81 hours 0.8 hours 1.68 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 0.83 hours 0.99 hours 0.86 hours
Certified Nursing Assistants Hours per Residents per Day 2.47 hours 2.44 hours 0.0 hours
Physical Therapy Staffing Hours per Resident Per Day 0.1 hours 0.06 hours 0.0 hours
Health Survey: BAPTIST LEAKE EXTENDED CARE FACILITY
Heath Survey Summary on 2014-02-07
Total Number of Health Deficiencies 6
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Heath Survey Summary on 2013-03-07
Total Number of Health Deficiencies 9
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Heath Survey Summary on 2012-01-29
Total Number of Health Deficiencies 1
Scope and Severity of most Severe Health Deficiency Isolated/Minimal harm or potential for actual harm
Health Survey Details: BAPTIST LEAKE EXTENDED CARE FACILITY
Inspection Results: 02/07/2014
Corrected Deficiency Scope and Severity
02/17/2014 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
02/12/2014 Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. Isolated/Minimal harm or potential for actual harm
02/12/2014 Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated/Minimal harm or potential for actual harm
02/12/2014 Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated/Minimal harm or potential for actual harm
02/12/2014 Have a program that investigates, controls and keeps infection from spreading. Widespread /Minimal harm or potential for actual harm
02/12/2014 Keep all essential equipment working safely. Widespread /Minimal harm or potential for actual harm
Inspection Results: 03/07/2013
Corrected Deficiency Scope and Severity
03/22/2013 Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated/Minimal harm or potential for actual harm
03/22/2013 Ensure services provided by the nursing facility meet professional standards of quality. Isolated/Minimal harm or potential for actual harm
03/22/2013 Provide housekeeping and maintenance services. Pattern/Minimal harm or potential for actual harm
03/22/2013 Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated/Minimal harm or potential for actual harm
03/22/2013 Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated/Minimal harm or potential for actual harm
03/22/2013 Store, cook, and serve food in a safe and clean way. Widespread /Minimal harm or potential for actual harm
03/22/2013 Have a program that investigates, controls and keeps infection from spreading. Isolated/Minimal harm or potential for actual harm
03/22/2013 Keep all essential equipment working safely. Isolated/Minimal harm or potential for actual harm
03/22/2013 Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated/Minimal harm or potential for actual harm
Inspection Results: 01/29/2012
Corrected Deficiency Scope and Severity
02/29/2012 Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated/Minimal harm or potential for actual harm

Fire Safety Survey: BAPTIST LEAKE EXTENDED CARE FACILITY
Fire Safety Survey Summary on 2014-02-07
Total Number of Fire SafetyDeficiencies 1
Scope and Severity of most Severe Health Deficiency Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Summary on 2013-03-07
Total Number of Fire SafetyDeficiencies 0
Scope and Severity of most Severe Health Deficiency
Fire Safety Survey Summary on 2012-01-27
Total Number of Fire SafetyDeficiencies 2
Scope and Severity of most Severe Health Deficiency Widespread /Minimal harm or potential for actual harm
Fire Safety Survey: BAPTIST LEAKE EXTENDED CARE FACILITY
Fire Safety Survey Results: 02/07/2014
Corrected Deficiency Severity
02/12/2014 Restrictions on the use of flammable curtains. Pattern/Minimal harm or potential for actual harm
Fire Safety Survey Results: 01/27/2012
Corrected Deficiency Severity
02/29/2012 An approved installation, maintenance and testing program for fire alarm systems. Widespread /Minimal harm or potential for actual harm
02/29/2012 An approved automatic sprinkler system connected to the fire alarm system. Pattern/Minimal harm or potential for actual harm

Resident Complaints: BAPTIST LEAKE EXTENDED CARE FACILITY
Date Complaint Substantiated: 09/09/2011
CorrectedCategoryDeficiencySeverity
09/26/2011Keep accurate, complete and organized clinical records on each resident that meet professional standards. D
09/26/2011Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. J
09/26/2011Allow residents the right to participate in the planning or revision of care and treatment. J
09/26/2011Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E
09/26/2011Protect each resident from mistreatment, neglect and misappropriation of personal property. J

Quality Measures: BAPTIST LEAKE EXTENDED CARE FACILITY
Quality Measures National Average Mississippi Average BAPTIST LEAKE EXTENDED CARE FACILITY
Overall quality rating NA NA 3
3
Long-Stay Residents
Percent of Long Stay Residents Whose Need for Help with ADLs has Increased 15.4% 18.4% 21.0%
Percent of Long Stay Residents Who Self Report Moderate to Severe Pain 8.3% 11.5% 15.3%
Percent of High Risk Long Stay Residents With Pressure Ulcers 6.1% 7.7% 12.5%
Percent of Long Stay Residents Who Lose Too Much Weight 7.2% 8.3% 7.9%
Percent of Low Risk Long Stay Residents Who Lose Control of Their Bowel or Bladder 43.9% 43.8% 17.9%
Percent of Long Stay Residents with a Catheter Inserted and Left in Their Bladder 3.2% 2.5% 4.8%
Percent of Long Stay Residents With a Urinary Tract Infection 6.2% 6.2% 6.3%
Percent of Long Stay Residents Who Have Depressive Symptoms 6.3% 2.2% 5.3%
Percent of Long Stay Residents Who Were Physically Restrained 1.4% 3.5% 0.0%
Percent of Long Stay Residents Experiencing One or More Falls with Major Injury 3.2% 2.8% 0.8%
Percent of Long Stay Residents Assessed and Appropriately Given the Seasonal Influenza Vaccine 92.7% 94.9% 100.0%
Percent of Long Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 94.3% 97.3% 100.0%
Percent of Long Stay Residents Who Received an Antipsychotic Medication 20.7% 24.5% 19.4%
Short-Stay Residents
Percent of Short Stay Residents Who Self Report Moderate to Severe Pain 19.2% 20.9% %
Percent of Short Stay Residents With Pressure Ulcers That Are New or Worsened 1.2% 1.2% %
Percent of Short Stay Residents Who Were Assessed and Appropriately Given the Seasonal Influenza Vaccine 83.4% 86.8% %
Percent of Short Stay Residents Assessed and Appropriately Given the Pneumococcal Vaccine 82.4% 88.4% %
Percent of Short Stay Residents Who Newly Received an Antipsychotic Medication 2.6% 3.3% %

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