| General |
| City |
| Tyler |
Tyler |
| State attribute explanation |
| Tx |
Tx |
| Street |
| 930 S Baxter |
900 S Baxter Ave |
| Zip Code |
| 75,701 |
75,701 |
| Phone |
| 9,035,972,068 |
9,035,978,192 |
|
Overall Star Rating |
| 2 |
1 |
|
Health Inspections Star Rating |
| 2 |
1 |
|
Nurse Staffing Star Rating |
| 2 |
1 |
|
Quality Measures Star Rating |
| 3 |
2 |
|
RN Only Star Rating |
| 2 |
1 |
|
Number of Certified Beds |
| 172 |
120 |
|
Total Number of Residents |
| 95 |
76 |
|
Percent of Occupied Beds |
| 55 % |
63 % |
| Health Survey Date |
| 6/8/2011 |
1/26/2012 |
| Fire Survey Date |
| 6/9/2011 |
1/24/2012 |
| Sprinkler Status |
| Fully Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| For Profit - Partnership |
For Profit - Partnership |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| Yes |
Yes |
| Resident and Family Councils |
| Resident |
Resident |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| No |
No |
| Special Focus Facility? |
| No |
No |
| Civil Money Penalty Count |
| 75.2 |
75.2 |
| Total Enforcement Actions Count |
| 75.2 |
75.2 |
| # of deficiencies |
| 9 |
17 |
|
| Staff Information |
| Number of Residents |
| 85 |
76 |
| Number of RN Hours Per Resident Per Day |
| 0.69 |
0.35 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.93 |
1.1 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.62 |
1.44 |
| Number of CNA Hours Per Resident Per Day |
| 0.07 |
75.2 |
| Number Therapy Hours Per Resident Per Day |
| 0.07 |
|
| Mistreatment Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 05/29/2012date Of Correction: 07/02/2012 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: 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: 05/29/2012date Of Correction: 07/02/2012 |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 2deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 05/29/2012date Of Correction: 07/02/2012 |
| Deficiency #4 |
|
Scope: Somelevel Of Harm: 2deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.survey Date: 05/29/2012date Of Correction: 07/02/2012 |
| Deficiency #5 |
|
Scope: Somelevel Of Harm: 2deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 10/18/2011date Of Correction: 10/19/2011 |
| Deficiency #6 |
|
Scope: Somelevel Of Harm: 2deficiency: 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: 10/18/2011date Of Correction: 10/19/2011 |
| Resident Rights Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: 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: 06/08/2011date Of Correction: 07/13/2011 |
|
| Deficiency #2 |
| Scope: Manylevel Of Harm: 2deficiency: Try To Resolve Each Resident's Complaints Quickly.survey Date: 03/31/2011date Of Correction: 04/24/2011 |
|
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 06/08/2011date Of Correction: 07/13/2011 |
Scope: Somelevel Of Harm: 2deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.survey Date: 12/28/2011date Of Correction: 12/29/2011 |
| Deficiency #2 |
| Scope: Manylevel Of Harm: 2deficiency: Provide Or Obtain Dental Services For Each Resident.survey Date: 03/31/2011date Of Correction: 04/24/2011 |
Scope: Somelevel Of Harm: 2deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 02/18/2011date Of Correction: 03/18/2011 |
| Deficiency #3 |
| Scope: Somelevel Of Harm: 2deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 09/14/2009date Of Correction: 09/29/2009 |
Scope: Somelevel Of Harm: 2deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.survey Date: 02/18/2011date Of Correction: 03/18/2011 |
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 09/14/2009date Of Correction: 09/29/2009 |
Scope: Somelevel Of Harm: 2deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 04/14/2010date Of Correction: 04/15/2010 |
| Resident Assessment Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.survey Date: 09/14/2009date Of Correction: 09/29/2009 |
|
| Administration Deficiencies |
| Deficiency #1 |
|
Scope: Manylevel Of Harm: 1deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 02/18/2011date Of Correction: 03/18/2011 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That Nurse Aides Show They Have The Skills And Techniques To Be Able To Care For Residents' Needs.survey Date: 02/18/2011date Of Correction: 03/18/2011 |
| Pharmacy Service Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.survey Date: 06/08/2011date Of Correction: 07/13/2011 |
Scope: Manylevel Of Harm: 2deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.survey Date: 10/05/2009date Of Correction: 10/06/2009 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 3deficiency: 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: 06/08/2011date Of Correction: 07/13/2011 |
|
| Nutrition and Dietary Deficiencies |
| Deficiency #1 |
|
Scope: Manylevel Of Harm: 2deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.survey Date: 10/31/2011date Of Correction: 11/11/2011 |
| Deficiency #2 |
|
Scope: Manylevel Of Harm: 2deficiency: 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: 10/31/2011date Of Correction: 11/11/2011 |
| Deficiency #3 |
|
Scope: Manylevel Of Harm: 2deficiency: Hire Sufficient Dietary Support Personnel.survey Date: 10/31/2011date Of Correction: 11/11/2011 |
| Deficiency #4 |
|
Scope: Manylevel Of Harm: 2deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.survey Date: 01/13/2010date Of Correction: 02/19/2010 |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 10.5 % |
35.8 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 1 % |
75.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 24.2 % |
13.3 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 75.2 % |
4.4 % |
| Percent of long-stay residents who lose too much weight |
| 7.1 % |
8.8 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 8.2 % |
7.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 3.6 % |
8.8 % |
| Percent of long-stay residents who have depressive symptoms |
| 4.2 % |
7.4 % |
| Percent of long-stay residents who were physically restrained |
| 3.6 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 60.5 % |
|
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 23 % |
9.4 / 10.4 |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 11 % |
10.6 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 1.50 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 2.4 % |
1.50 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 13.3 % |
32 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 0.3 % |
0.9 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 18.3 % |
17.2 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 1.9 % |
6.8 % |
| Percent of long-stay residents who lose too much weight |
| 6.6 % |
13.3 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 40.7 % |
29.2 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 8.4 % |
6.7 % |
| Percent of long-stay residents with a urinary tract infection |
| 6.6 % |
8.7 % |
| Percent of long-stay residents who have depressive symptoms |
| 8.5 % |
9.9:1 |
| Percent of long-stay residents who were physically restrained |
| 1.6 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 1.2 % |
2.3 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 51.7 % |
32.3 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 27.7 % |
15.6 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 28.7 % |
17 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 2.1 % |
33.1 % |