| General |
| City |
| Fredericksburg |
Amarillo |
| State attribute explanation |
| Tx |
Tx |
| Street |
| 1208 |
5601 Plum Creek Dr |
| Zip Code |
| 78,624 |
79,124 |
| Phone |
| 8,309,973,704 |
8,063,511,000 |
|
Overall Star Rating |
| 4 |
2 |
|
Health Inspections Star Rating |
| 4 |
1 |
|
Nurse Staffing Star Rating |
| 3 |
4 |
|
Quality Measures Star Rating |
| 2 |
2 |
|
RN Only Star Rating |
| 2 |
4 |
|
Number of Certified Beds |
| 132 |
99 |
|
Total Number of Residents |
| 103 |
82 |
|
Percent of Occupied Beds |
| 78 % |
83 % |
| Health Survey Date |
| 4/21/2011 |
6/8/2012 |
| Fire Survey Date |
| 4/20/2011 |
6/8/2012 |
| 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 |
Both |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| No |
No |
| Special Focus Facility? |
| No |
Yes |
| Civil Money Penalty Count |
| 75.2 |
7 |
| Total Enforcement Actions Count |
| 75.2 |
7 |
| # of deficiencies |
|
23 |
|
| Staff Information |
| Number of Residents |
| 96 |
82 |
| Number of RN Hours Per Resident Per Day |
| 0.34 |
1.03 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.72 |
0.99 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.07 |
2.02 |
| Number of CNA Hours Per Resident Per Day |
| 0.03 |
0.13 |
| Number Therapy Hours Per Resident Per Day |
| 0.03 |
0.13 |
| Environmental Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 03/26/2011date Of Correction: 04/29/2011 |
| 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: 03/24/2010date Of Correction: 03/09/2010 |
| Mistreatment Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 4deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 12/23/2011date Of Correction: 01/24/2012 |
| 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: 12/23/2011date Of Correction: 01/24/2012 |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 4deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 12/23/2011date Of Correction: 01/24/2012 |
| Deficiency #4 |
|
Scope: Somelevel Of Harm: 4deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 09/27/2011date Of Correction: 10/26/2011 |
| Deficiency #5 |
|
Scope: Somelevel Of Harm: 4deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 09/27/2011date Of Correction: 10/26/2011 |
| Deficiency #6 |
|
Scope: Somelevel Of Harm: 2deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 06/09/2010date Of Correction: 07/09/2010 |
| Deficiency #7 |
|
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: 06/09/2010date Of Correction: 07/09/2010 |
| Deficiency #8 |
|
Scope: Fewlevel Of Harm: 4deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 10/23/2009date Of Correction: 11/20/2009 |
| Deficiency #9 |
|
Scope: Fewlevel Of Harm: 4deficiency: 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: 10/23/2009date Of Correction: 11/20/2009 |
| Deficiency #10 |
|
Scope: Fewlevel Of Harm: 4deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 10/23/2009date Of Correction: 11/20/2009 |
| Deficiency #11 |
|
Scope: Somelevel Of Harm: 2deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 07/28/2009date Of Correction: 07/30/2009 |
| Deficiency #12 |
|
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: 07/28/2009date Of Correction: 07/30/2009 |
| Resident Rights Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 4deficiency: 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: 12/23/2011date Of Correction: 01/24/2012 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 4deficiency: 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: 09/27/2011date Of Correction: 10/26/2011 |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 2deficiency: Give The Resident The Right To Receive Visitors.survey Date: 10/23/2009date Of Correction: 11/20/2009 |
| Quality Care Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 3deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 06/08/2012date Of Correction: Not Available |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 4deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 12/23/2011date Of Correction: 01/24/2012 |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 4deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 12/23/2011date Of Correction: 01/24/2012 |
| Deficiency #4 |
|
Scope: Fewlevel Of Harm: 4deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 10/23/2009date Of Correction: 11/20/2009 |
| Administration Deficiencies |
| Deficiency #1 |
|
Scope: Manylevel Of Harm: 1deficiency: Post Nurse Staffing Information/data On A Daily Basis.survey Date: 07/28/2009date Of Correction: 07/29/2009 |
| Pharmacy Service Deficiencies |
| Deficiency #1 |
|
Scope: Somelevel Of Harm: 4deficiency: 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: 09/27/2011date Of Correction: 10/26/2011 |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 19.3 % |
17.3:1 |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 2.1 % |
1.2 % |
| 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 % |
18.2:1 |
| Percent of long-stay residents who lose too much weight |
| 13.3 % |
11.3 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 57.1 % |
|
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 4.9 % |
16.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 5.6:1 |
5.7 % |
| Percent of long-stay residents who have depressive symptoms |
| 12.2 % |
3.7 % |
| 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 % |
32.4 (90.3) |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 96.4 % |
59.3 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 94.9 % |
64.1 % |
| 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 % |
1.9 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 23.6 % |
17.6 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 3.8 % |
1.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 20.4 % |
14.4 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 7.2 % |
10.6 % |
| Percent of long-stay residents who lose too much weight |
| 16.2 % |
12.1:1 |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 52.6 % |
13.4 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 4.1 % |
19.7 % |
| Percent of long-stay residents with a urinary tract infection |
| 5.8 % |
9.1 % |
| Percent of long-stay residents who have depressive symptoms |
| 18.4 % |
1.2 % |
| 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 % |
1.8 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 21.4 % |
26.6 (79.9) |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 94.8 % |
46.2 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 94.1 % |
50.2 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 29 % |
27.3 % |