WESTWARD TRAILS REHABILITATION AND HEALTHCARE CENT

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General
City	NACOGDOCHES	vs	0% Nursing Homes USA have NACOGDOCHES
State attribute explanation	TX	vs	7.6% Nursing Homes USA have TX	compare TX Nursing Homes USA
Street	3001 WESTWARD DR
Zip Code	75964
Phone	9365692631
Overall Star Rating	1 (2.11 lower than average)	vs	3.11	Compare similar Overall Star Rating (1)
Health Inspections Star Rating	1 (1.83 lower than average)	vs	2.83	Compare similar Health Inspections Star Rating (1)
Nurse Staffing Star Rating	3 (0.17 lower than average)	vs	3.17	Compare similar Nurse Staffing Star Rating (3)
Quality Measures Star Rating	2 (1.31 lower than average)	vs	3.31	Compare similar Quality Measures Star Rating (2)
RN Only Star Rating	2 (1.17 lower than average)	vs	3.17	Compare similar RN Only Star Rating (2)
Number of Certified Beds	108 (0.94 lower than average)	vs	108.94	Compare similar Number of Certified Beds (108)
Total Number of Residents	58 (33.25 lower than average)	vs	91.25	Compare similar Total Number of Residents (58)
Percent of Occupied Beds	54 % (29.65 % lower than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (54) %
Health Survey Date	3/28/2012
Fire Survey Date	3/27/2012
Sprinkler Status	Fully Sprinklered	vs	90.2% Nursing Homes USA have Fully Sprinklered
Program Participation	Medicare And Medicaid	vs	91.5% Nursing Homes USA have Medicare and Medicaid	compare Medicare and Medicaid Nursing Homes USA
Type of Ownership	For Profit - Corporation	vs	56.7% Nursing Homes USA have For profit - Corporation	compare For profit - Corporation Nursing Homes USA
Located Within a Hospital?	No	vs	93.6% Nursing Homes USA don't have Located Within a Hospital?	Compare similar don't have Located Within a Hospital?
Multi Nursing Home Ownership?	Yes	vs	54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils	RESIDENT	vs	66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community?	No	vs	90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey?	No	vs	68.7% Nursing Homes USA don't have Quality Indicator Survey?
Special Focus Facility?	No	vs	99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count	3 (55.16 lower than average)	vs	58.16
Total Enforcement Actions Count	3 (53.31 lower than average)	vs	56.31
# of deficiencies	34 (26.52 higher than average)	vs	7.48

Staff Information
Number of Residents	58 (33.38 lower than average)	vs	91.38
Number of RN Hours Per Resident Per Day	0.44 (0.33 lower than average)	vs	0.77
Number of LPN/LVN Hours Per Resident Per Day	0.73 (0.11 lower than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	1.17 (0.42 lower than average)	vs	1.59
Number of CNA Hours Per Resident Per Day	0.09 (5.4 lower than average)	vs	5.49
Number Therapy Hours Per Resident Per Day	0.09 (0.01 lower than average)	vs	0.10

Environmental Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Make Sure That The Nursing Home Area Is Safe, Easy To Use, Clean And Comfortable For Residents, Staff And The Public. survey Date: 11/18/2011 date Of Correction: 12/12/2011
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 11/18/2011 date Of Correction: 12/12/2011
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 03/15/2011 date Of Correction: 04/13/2011
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 01/10/2011 date Of Correction: 02/08/2011
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 12/30/2009 date Of Correction: 01/29/2010
Deficiency #6		Scope: Some level Of Harm: 2 deficiency: Make Sure There Is A Pest Control Program To Prevent/deal With Mice, Insects, Or Other Pests. survey Date: 06/16/2009 date Of Correction: 07/16/2009

Mistreatment Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 01/10/2011 date Of Correction: 02/08/2011
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: 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. survey Date: 01/10/2011 date Of Correction: 02/08/2011
Deficiency #3		Scope: Many level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 07/16/2010 date Of Correction: 08/14/2010
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: 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. survey Date: 07/16/2010 date Of Correction: 08/14/2010
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 06/17/2010 date Of Correction: 08/14/2010
Deficiency #6		Scope: Some level Of Harm: 2 deficiency: 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. survey Date: 06/17/2010 date Of Correction: 08/14/2010

Resident Rights Deficiencies
Deficiency #1		Scope: Many level Of Harm: 2 deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident. survey Date: 11/18/2011 date Of Correction: 12/12/2011
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Reasonably Accommodate The Needs And Preferences Of Each Resident. survey Date: 03/15/2011 date Of Correction: 04/13/2011
Deficiency #3		Scope: Some level Of Harm: 3 deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident. survey Date: 03/15/2011 date Of Correction: 04/13/2011

Quality Care Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 12/15/2011 date Of Correction: 01/08/2012
Deficiency #2		Scope: Some level Of Harm: 3 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 03/15/2011 date Of Correction: 04/13/2011
Deficiency #3		Scope: Some level Of Harm: 3 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 03/15/2011 date Of Correction: 04/13/2011
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 01/10/2011 date Of Correction: 02/08/2011
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being. survey Date: 10/09/2010 date Of Correction: 11/07/2010
Deficiency #6		Scope: Some level Of Harm: 2 deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene. survey Date: 10/09/2010 date Of Correction: 11/07/2010
Deficiency #7		Scope: Some level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 07/16/2010 date Of Correction: 08/14/2010
Deficiency #8		Scope: Some level Of Harm: 2 deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses. survey Date: 04/27/2009 date Of Correction: 05/21/2009
Deficiency #9		Scope: Some level Of Harm: 3 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 04/27/2009 date Of Correction: 05/21/2009

Resident Assessment Deficiencies
Deficiency #1		Scope: Some level Of Harm: 3 deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured. survey Date: 03/15/2011 date Of Correction: 04/13/2011
Deficiency #2		Scope: Some level Of Harm: 3 deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity. survey Date: 03/15/2011 date Of Correction: 04/13/2011
Deficiency #3		Scope: Some level Of Harm: 3 deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity. survey Date: 04/27/2009 date Of Correction: 05/21/2009

Administration Deficiencies
Deficiency #1		Scope: Many level Of Harm: 2 deficiency: Give Or Get Quality Lab Services/tests In A Timely Manner To Meet The Needs Of Residents. survey Date: 06/09/2011 date Of Correction: 07/08/2011

Pharmacy Service Deficiencies
Deficiency #1		Scope: Many level Of Harm: 2 deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards. survey Date: 06/09/2011 date Of Correction: 07/08/2011
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Make Sure That Residents Are Safe From Serious Medication Errors. survey Date: 06/09/2011 date Of Correction: 07/08/2011
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 03/15/2011 date Of Correction: 04/13/2011
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Make Sure That Residents Are Safe From Serious Medication Errors. survey Date: 03/15/2011 date Of Correction: 04/13/2011
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 01/10/2011 date Of Correction: 02/08/2011
Deficiency #6		Scope: Some level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 06/17/2010 date Of Correction: 08/14/2010

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication	21.8 % (3.29 % lower than average)	vs	25.09 %
Percent of long-stay residents whose need for help with daily activities has increased	6.8 % (26.15 % lower than average)	vs	32.95 %
Percent of long-stay residents who self-report moderate to severe pain	14.9-28 % (1.76 % lower than average)	vs	16.66 %
Percent of long-stay high-risk residents with pressure ulcers	10.3:1 %
Percent of long-stay residents who lose too much weight	5.2 % (6.63 % lower than average)	vs	11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	5.2 % (10.43 % lower than average)	vs	15.63 %
Percent of long-stay residents with a urinary tract infection	6.9 % (6.56 % lower than average)	vs	13.46 %
Percent of long-stay residents who have depressive symptoms	75.2 % (46.82 % higher than average)	vs	28.38 %
Percent of long-stay residents who were physically restrained	75.2 % (31.52 % higher than average)	vs	43.68 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	60.6 % (24.04 % lower than average)	vs	84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	68.6 % (15.34 % lower than average)	vs	83.94 %
Percent of short-stay residents who newly received an antipsychotic medication	75.2 (29.3 higher than average)	vs	45.90
Percent of long-stay residents experiencing one or more falls with major injury	3.4 % (12.12 % lower than average)	vs	15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication	22.1 (71.8) % (3.29 % lower than average)	vs	25.39 %
Percent of long-stay residents whose need for help with daily activities has increased	2.9 % (20.8 % lower than average)	vs	23.70 %
Percent of long-stay residents who self-report moderate to severe pain	19.5-24 % (5.4 % higher than average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	13.1:1 %
Percent of long-stay residents who lose too much weight	5.5 % (3 % lower than average)	vs	8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	41.1 % (2.28 % lower than average)	vs	43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	3.4 % (7.25 % lower than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	8.2 % (1.38 % lower than average)	vs	9.58 %
Percent of long-stay residents who have depressive symptoms	75.2 % (55.34 % higher than average)	vs	19.86 %
Percent of long-stay residents who were physically restrained	75.2 % (36.67 % higher than average)	vs	38.53 %
Percent of long-stay residents experiencing one or more falls with major injury	4.8 % (5.93 % lower than average)	vs	10.73 %
Percent of short-stay residents who self-report moderate to severe pain	24.1 % (0.66 % lower than average)	vs	24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	47.3 % (34.14 % lower than average)	vs	81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	52.8 % (21.95 % lower than average)	vs	74.75 %
Percent of short-stay residents who newly received an antipsychotic medication	23.3 % (5.96 % higher than average)	vs	17.34 %