General |
City |
Fredericksburg |
Waco |
State attribute explanation |
Tx |
Tx |
Street |
1208 |
2501 Maple Ave |
Zip Code |
78,624 |
76,707 |
Phone |
8,309,973,704 |
2,547,520,311 |
Overall Star Rating |
4 |
1 |
Health Inspections Star Rating |
4 |
2 |
Nurse Staffing Star Rating |
3 |
1 |
Quality Measures Star Rating |
2 |
2 |
RN Only Star Rating |
2 |
1 |
Number of Certified Beds |
132 |
222 |
Total Number of Residents |
103 |
130 |
Percent of Occupied Beds |
78 % |
59 % |
Health Survey Date |
4/21/2011 |
1/26/2012 |
Fire Survey Date |
4/20/2011 |
1/26/2012 |
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 |
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 |
5 |
# of deficiencies |
|
28 |
|
Staff Information |
Number of Residents |
96 |
130 |
Number of RN Hours Per Resident Per Day |
0.34 |
0.22 |
Number of LPN/LVN Hours Per Resident Per Day |
0.72 |
0.78 |
Total Number of Licensed Staff Hours Per Resident Per Day |
1.07 |
1 |
Number of CNA Hours Per Resident Per Day |
0.03 |
0.09 |
Number Therapy Hours Per Resident Per Day |
0.03 |
0.09 |
Environmental Deficiencies |
Deficiency #1 |
|
Scope: Fewlevel Of Harm: 3deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 04/12/2011date Of Correction: 05/02/2011 |
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: 10/15/2010date Of Correction: 11/15/2010 |
Deficiency #3 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Housekeeping And Maintenance Services.survey Date: 09/12/2010date Of Correction: 10/15/2010 |
Deficiency #4 |
|
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: 08/01/2009date Of Correction: 09/05/2009 |
Resident Rights Deficiencies |
Deficiency #1 |
|
Scope: Fewlevel 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: 04/12/2011date Of Correction: 05/05/2011 |
Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Reasonably Accommodate The Needs And Preferences Of Each Resident.survey Date: 09/12/2010date Of Correction: 10/15/2010 |
Quality Care Deficiencies |
Deficiency #1 |
|
Scope: Fewlevel Of Harm: 3deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 04/12/2011date Of Correction: 05/02/2011 |
Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.survey Date: 05/28/2010date Of Correction: 06/30/2010 |
Deficiency #3 |
|
Scope: Somelevel Of Harm: 2deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.survey Date: 04/28/2010date Of Correction: 05/21/2010 |
Resident Assessment Deficiencies |
Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That Doctors Visit Residents Regularly, As Required.survey Date: 11/22/2011date Of Correction: 12/20/2011 |
Deficiency #2 |
|
Scope: Fewlevel 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: 03/25/2011date Of Correction: 04/18/2011 |
Deficiency #3 |
|
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: 02/03/2011date Of Correction: 03/04/2011 |
Deficiency #4 |
|
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: 08/01/2009date Of Correction: 09/05/2009 |
Deficiency #5 |
|
Scope: Fewlevel 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: 06/11/2009date Of Correction: 07/11/2009 |
Administration Deficiencies |
Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 03/25/2011date Of Correction: 04/18/2011 |
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: 09/12/2010date Of Correction: 10/15/2010 |
Deficiency #3 |
|
Scope: Fewlevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 06/11/2009date Of Correction: 07/11/2009 |
Pharmacy Service Deficiencies |
Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.survey Date: 09/12/2010date Of Correction: 10/15/2010 |
Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.survey Date: 09/12/2010date Of Correction: 10/15/2010 |
Deficiency #3 |
|
Scope: Somelevel Of Harm: 2deficiency: Keep The Rate Of Medication Errors (wrong Drug, Wrong Dose, Wrong Time) To Less Than 5%.survey Date: 09/12/2010date Of Correction: 10/15/2010 |
Deficiency #4 |
|
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: 08/12/2010date Of Correction: 09/15/2010 |
Deficiency #5 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.survey Date: 08/12/2010date Of Correction: 09/15/2010 |
Deficiency #6 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.survey Date: 04/28/2010date Of Correction: 05/21/2010 |
Deficiency #7 |
|
Scope: Fewlevel 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: 02/26/2010date Of Correction: 03/23/2010 |
Deficiency #8 |
|
Scope: Fewlevel 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: 12/10/2009date Of Correction: 01/15/2010 |
Deficiency #9 |
|
Scope: Fewlevel 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: 06/11/2009date Of Correction: 07/11/2009 |
Nutrition and Dietary Deficiencies |
Deficiency #1 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That Special Or Therapeutic Diets Are Ordered By The Attending Doctor.survey Date: 10/15/2010date Of Correction: 11/15/2010 |
Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.survey Date: 08/12/2010date Of Correction: 09/15/2010 |
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 % |
1.9 % |
Percent of long-stay residents who self-report moderate to severe pain |
16.4 % |
11.3 % |
Percent of long-stay high-risk residents with pressure ulcers |
10.9 % |
6.8 % |
Percent of long-stay residents who lose too much weight |
13.3 % |
6 % |
Percent of long-stay low-risk residents who lose control of their bowels or bladder |
57.1 % |
20 % |
Percent of long-stay residents who have had a catheter inserted and left in their bladder |
4.9 % |
10.7:1 |
Percent of long-stay residents with a urinary tract infection |
5.6:1 |
6.8 % |
Percent of long-stay residents who have depressive symptoms |
12.2 % |
9.1 % |
Percent of long-stay residents who were physically restrained |
75.2 % |
13.3 % |
Percent of short-stay residents who self-report moderate to severe pain |
22 % |
27.3 % |
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
96.4 % |
77.6 % |
Percent of short-stay residents with Pressure ulcers that are new or worsened |
94.9 % |
79.6 % |
Percent of short-stay residents who newly received an antipsychotic medication |
75.2 |
7.7 % |
Percent of long-stay residents experiencing one or more falls with major injury |
2.20 % |
0.8 % |
Quality Measures Q3 |
Percent of long-stay residents who received an antipsychotic medication |
23.6 % |
22.4:1 |
Percent of long-stay residents whose need for help with daily activities has increased |
3.8 % |
3.8 % |
Percent of long-stay residents who self-report moderate to severe pain |
20.4 % |
11.1 % |
Percent of long-stay high-risk residents with pressure ulcers |
7.2 % |
8.1 / 8.8 |
Percent of long-stay residents who lose too much weight |
16.2 % |
7.5 % |
Percent of long-stay low-risk residents who lose control of their bowels or bladder |
52.6 % |
20.4 % |
Percent of long-stay residents who have had a catheter inserted and left in their bladder |
4.1 % |
9.3 % |
Percent of long-stay residents with a urinary tract infection |
5.8 % |
7.5 % |
Percent of long-stay residents who have depressive symptoms |
18.4 % |
7 % |
Percent of long-stay residents who were physically restrained |
0.4 % |
13 % |
Percent of long-stay residents experiencing one or more falls with major injury |
3.9 % |
1.6 % |
Percent of short-stay residents who self-report moderate to severe pain |
21.4 % |
22.6 % |
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
94.8 % |
56.9 % |
Percent of short-stay residents with Pressure ulcers that are new or worsened |
94.1 % |
59.7 % |
Percent of short-stay residents who newly received an antipsychotic medication |
29 % |
18.3 % |