WOODWIND LAKES HEALTH AND REHABILITATION CENTER

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General
City	Houston	vs	0.4% Nursing Homes USA have Houston
State attribute explanation	TX	vs	7.6% Nursing Homes USA have TX	compare TX Nursing Homes USA
Street	7215 WINDFERN RD
Zip Code	77040
Phone	7134668933
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	4 (0.83 higher than average)	vs	3.17	Compare similar RN Only Star Rating (4)
Number of Certified Beds	180 (71.06 higher than average)	vs	108.94	Compare similar Number of Certified Beds (180)
Total Number of Residents	165 (73.75 higher than average)	vs	91.25	Compare similar Total Number of Residents (165)
Percent of Occupied Beds	92 % (8.35 % higher than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (92) %
Health Survey Date	4/29/2011
Fire Survey Date	4/27/2011
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	Both	vs	29.8% Nursing Homes USA have Both
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	1 (57.16 lower than average)	vs	58.16
Total Enforcement Actions Count	2 (54.31 lower than average)	vs	56.31
# of deficiencies	42 (34.52 higher than average)	vs	7.48

Staff Information
Number of Residents	122 (30.62 higher than average)	vs	91.38
Number of RN Hours Per Resident Per Day	0.86 (0.09 higher than average)	vs	0.77
Number of LPN/LVN Hours Per Resident Per Day	0.61 (0.23 lower than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	1.47 (0.12 lower than average)	vs	1.59
Number of CNA Hours Per Resident Per Day	0.11 (5.38 lower than average)	vs	5.49
Number Therapy Hours Per Resident Per Day	0.11 (0.01 higher than average)	vs	0.10

Environmental Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 04/07/2011 date Of Correction: Not Available
Deficiency #4		Scope: Few level Of Harm: 3 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 12/29/2010 date Of Correction: 01/24/2011
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: 09/15/2009 date Of Correction: 10/13/2009
Deficiency #6		Scope: Some level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 05/01/2009 date Of Correction: 06/01/2009

Mistreatment Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 04/07/2011 date Of Correction: 04/29/2011
Deficiency #2		Scope: Few 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: 04/07/2011 date Of Correction: 04/29/2011
Deficiency #3		Scope: Few level Of Harm: 3 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 07/01/2010 date Of Correction: 07/29/2010
Deficiency #4		Scope: Few level Of Harm: 3 deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property. survey Date: 07/01/2010 date Of Correction: 07/29/2010

Resident Rights Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Give Each Resident A Notice Of Rights, Rules, Services And Charges. Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items And Services Medicaid Covers And Which The Resident Must Pay For. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality. survey Date: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #3		Scope: Few 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: 07/01/2010 date Of Correction: 07/29/2010
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality. survey Date: 09/15/2009 date Of Correction: 10/13/2009
Deficiency #5		Scope: Few level Of Harm: 2 deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality. survey Date: 05/01/2009 date Of Correction: 06/01/2009

Quality Care Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #2		Scope: Few level Of Harm: 3 deficiency: Make Sure That Residents With Reduced Range Of Motion Get Proper Treatment And Services To Increase Range Of Motion. survey Date: 04/29/2011 date Of Correction: Not Available
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Make Sure That Each Resident Who Enters The Nursing Home Without A Catheter Is Not Given A Catheter, And Receive Proper Services To Prevent Urinary Tract Infections And Restore Normal Bladder Function. survey Date: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #4		Scope: Few level Of Harm: 3 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 04/29/2011 date Of Correction: Not Available
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care. survey Date: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #6		Scope: Few level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 04/07/2011 date Of Correction: 04/29/2011
Deficiency #7		Scope: Few level Of Harm: 3 deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care. survey Date: 12/29/2010 date Of Correction: 01/24/2011

Resident Assessment Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Check And Assess Each Resident's Assessment At Least Every 3 Months. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Review Or Revise The Resident's Care Plan After Any Major Change In A Resident's Physical Or Mental Health. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Assess The Resident When The Resident Enters The Nursing Home, In A Timely Manner. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #5		Scope: Some level Of Harm: 2 deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured. survey Date: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #6		Scope: Few level Of Harm: 2 deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional. survey Date: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #7		Scope: Few level Of Harm: 2 deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured. survey Date: 04/07/2011 date Of Correction: Not Available
Deficiency #8		Scope: Few level Of Harm: 2 deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional. survey Date: 04/07/2011 date Of Correction: Not Available
Deficiency #9		Scope: Some level Of Harm: 2 deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured. survey Date: 07/01/2010 date Of Correction: 07/29/2010
Deficiency #10		Scope: Few level Of Harm: 2 deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured. survey Date: 05/01/2009 date Of Correction: 06/01/2009

Administration Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Quickly Tell The Resident's Doctor The Results Of Lab Tests. survey Date: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Make Sure That Nurse Aides Show They Have The Skills And Techniques To Be Able To Care For Residents' Needs. survey Date: 05/01/2009 date Of Correction: 06/01/2009

Pharmacy Service Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards. survey Date: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #2		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: 04/29/2011 date Of Correction: 05/17/2011
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being. survey Date: 07/01/2010 date Of Correction: 07/29/2010
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Make Sure That Residents Are Safe From Serious Medication Errors. survey Date: 05/01/2009 date Of Correction: 06/01/2009

Nutrition and Dietary Deficiencies
Deficiency #1		Scope: Many level Of Harm: 2 deficiency: Store, Cook, And Serve Food In A Safe And Clean Way. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #2		Scope: Many level Of Harm: 2 deficiency: Prepare Food That Is Nutritional, Appetizing, Tasty, Attractive, Well-cooked, And At The Right Temperature. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #3		Scope: Some level Of Harm: 2 deficiency: Make Sure Menus Meet The Resident's Nutritional Needs And That There Is A Prepared Menu By Which Nutritious Meals Have Been Planned For The Resident And Followed. survey Date: 05/18/2012 date Of Correction: 06/18/2012
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Store, Cook, And Serve Food In A Safe And Clean Way. survey Date: 10/08/2009 date Of Correction: 10/14/2009

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication	43.6 % (18.51 % higher than average)	vs	25.09 %
Percent of long-stay residents whose need for help with daily activities has increased	1.4 % (31.55 % lower than average)	vs	32.95 %
Percent of long-stay residents who self-report moderate to severe pain	9.8 % (6.86 % lower than average)	vs	16.66 %
Percent of long-stay high-risk residents with pressure ulcers	7.4 % (5.18 % lower than average)	vs	12.58 %
Percent of long-stay residents who lose too much weight	2.6 / 3 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	70.3 % (25.76 % higher than average)	vs	44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	1.50 % (14.13 % lower than average)	vs	15.63 %
Percent of long-stay residents with a urinary tract infection	17.5 % (4.04 % higher than average)	vs	13.46 %
Percent of long-stay residents who have depressive symptoms	0.9 % (27.48 % lower than average)	vs	28.38 %
Percent of long-stay residents who were physically restrained	1.7 % (41.98 % lower than average)	vs	43.68 %
Percent of short-stay residents who self-report moderate to severe pain	23.5 % (1.52 % lower than average)	vs	25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	40 % (44.64 % lower than average)	vs	84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	32.5 % (51.44 % lower than average)	vs	83.94 %
Percent of short-stay residents who newly received an antipsychotic medication	10 % (35.9 % lower 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	43 % (17.61 % higher than average)	vs	25.39 %
Percent of long-stay residents whose need for help with daily activities has increased	1.8 % (21.9 % lower than average)	vs	23.70 %
Percent of long-stay residents who self-report moderate to severe pain	13.5 % (0.6 % lower than average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	7.4 % (1.82 % lower than average)	vs	9.22 %
Percent of long-stay residents who lose too much weight	8.4 % (0.1 % lower than average)	vs	8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	77.5 % (34.12 % higher than average)	vs	43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	2.8 % (7.85 % lower than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	15.9:1 %
Percent of long-stay residents who have depressive symptoms	3.6 % (16.26 % lower than average)	vs	19.86 %
Percent of long-stay residents who were physically restrained	1.4 % (37.13 % lower than average)	vs	38.53 %
Percent of long-stay residents experiencing one or more falls with major injury	3.9 % (6.83 % lower than average)	vs	10.73 %
Percent of short-stay residents who self-report moderate to severe pain	18 % (6.76 % lower than average)	vs	24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	52.2 % (29.24 % lower than average)	vs	81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	45.3 % (29.45 % lower than average)	vs	74.75 %
Percent of short-stay residents who newly received an antipsychotic medication	41.8 % (24.46 % higher than average)	vs	17.34 %