| General |
| City |
| Fredericksburg |
Houston |
| State attribute explanation |
| Tx |
Tx |
| Street |
| 1208 |
7499 Stanwick Dr |
| Zip Code |
| 78,624 |
77,087 |
| Phone |
| 8,309,973,704 |
7,136,448,048 |
|
Overall Star Rating |
| 4 |
1 |
|
Health Inspections Star Rating |
| 4 |
1 |
|
Nurse Staffing Star Rating |
| 3 |
1 |
|
Quality Measures Star Rating |
| 2 |
4 |
|
RN Only Star Rating |
| 2 |
2 |
|
Number of Certified Beds |
| 132 |
120 |
|
Total Number of Residents |
| 103 |
104 |
|
Percent of Occupied Beds |
| 78 % |
87 % |
| Health Survey Date |
| 4/21/2011 |
6/24/2011 |
| Fire Survey Date |
| 4/20/2011 |
6/23/2011 |
| Sprinkler Status |
| Fully Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| For Profit - Corporation |
For Profit - Corporation |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| No |
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 |
4 |
| Total Enforcement Actions Count |
| 75.2 |
4 |
| # of deficiencies |
|
18 |
|
| Staff Information |
| Number of Residents |
| 96 |
104 |
| Number of RN Hours Per Resident Per Day |
| 0.34 |
0.64 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.72 |
0.69 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.07 |
1.33 |
| Number of CNA Hours Per Resident Per Day |
| 0.03 |
0.06 |
| Number Therapy Hours Per Resident Per Day |
| 0.03 |
0.06 |
| Environmental Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 02/08/2012date Of Correction: 02/24/2012 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 05/04/2009date Of Correction: 06/12/2009 |
| Mistreatment Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 02/08/2012date Of Correction: 02/24/2012 |
| Resident Rights Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 3deficiency: 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: 10/24/2010date Of Correction: 11/05/2010 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.survey Date: 05/04/2009date Of Correction: 06/12/2009 |
| Quality Care Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.survey Date: 08/10/2011date Of Correction: 09/13/2011 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Develop Policies And Procedures For Influenza And Pneumococcal Immunizations.survey Date: 06/24/2011date Of Correction: 07/27/2011 |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 3deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 10/24/2010date Of Correction: 11/05/2010 |
| 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: 09/03/2010date Of Correction: 10/01/2010 |
| Deficiency #5 |
|
Scope: Somelevel Of Harm: 2deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 05/13/2010date Of Correction: 06/30/2010 |
| Deficiency #6 |
|
Scope: Fewlevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 05/04/2009date Of Correction: 06/12/2009 |
| Resident Assessment Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional.survey Date: 06/24/2011date Of Correction: 07/27/2011 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.survey Date: 05/13/2010date Of Correction: 06/30/2010 |
| Administration Deficiencies |
| Deficiency #1 |
|
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: 05/03/2012date Of Correction: 05/25/2012 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 3deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .survey Date: 10/24/2010date Of Correction: 11/05/2010 |
| Deficiency #3 |
|
Scope: Fewlevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 09/03/2010date Of Correction: 10/01/2010 |
| Pharmacy Service Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.survey Date: 08/10/2011date Of Correction: 09/13/2011 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 3deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.survey Date: 10/24/2010date Of Correction: 11/05/2010 |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 19.3 % |
23.3 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 2.1 % |
75.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 16.4 % |
15.5 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 10.9 % |
13.5 % |
| Percent of long-stay residents who lose too much weight |
| 13.3 % |
5.2 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 57.1 % |
46.7 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 4.9 % |
1.6 % |
| Percent of long-stay residents with a urinary tract infection |
| 5.6:1 |
3 % |
| Percent of long-stay residents who have depressive symptoms |
| 12.2 % |
7.4 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 22 % |
|
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 96.4 % |
10.7:1 |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 94.9 % |
15.6 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 |
75.2 |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 2.20 % |
0.9 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 23.6 % |
22.9 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 3.8 % |
0.6 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 20.4 % |
23.6 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 7.2 % |
14.1 % |
| Percent of long-stay residents who lose too much weight |
| 16.2 % |
5.1 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 52.6 % |
53.8 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 4.1 % |
2.1 % |
| Percent of long-stay residents with a urinary tract infection |
| 5.8 % |
2.1 % |
| Percent of long-stay residents who have depressive symptoms |
| 18.4 % |
8.8 % |
| Percent of long-stay residents who were physically restrained |
| 0.4 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 3.9 % |
2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 21.4 % |
29.2 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 94.8 % |
27.3 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 94.1 % |
12.3:1 |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 29 % |
75.2 % |