| General |
| City |
| Bryan |
Waco |
| State attribute explanation |
| Tx |
Tx |
| Street |
| 1401 Memorial Dr |
2501 Maple Ave |
| Zip Code |
| 77,802 |
76,707 |
| Phone |
| 9,797,767,521 |
2,547,520,311 |
|
Overall Star Rating |
| 1 |
1 |
|
Health Inspections Star Rating |
| 2 |
2 |
|
Nurse Staffing Star Rating |
| 2 |
1 |
|
Quality Measures Star Rating |
| 1 |
2 |
|
RN Only Star Rating |
| 1 |
1 |
|
Number of Certified Beds |
| 116 |
222 |
|
Total Number of Residents |
| 82 |
130 |
|
Percent of Occupied Beds |
| 71 % |
59 % |
| Health Survey Date |
| 9/8/2011 |
1/26/2012 |
| Fire Survey Date |
| 9/6/2011 |
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 |
| Both |
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 |
| 13 |
28 |
|
| Staff Information |
| Number of Residents |
| 82 |
130 |
| Number of RN Hours Per Resident Per Day |
| 0.34 |
0.22 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.93 |
0.78 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.27 |
1 |
| Number of CNA Hours Per Resident Per Day |
| 0.01 |
0.09 |
| Number Therapy Hours Per Resident Per Day |
| 0.01 |
0.09 |
| 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: 03/04/2010date Of Correction: 03/31/2010 |
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: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 06/13/2009date Of Correction: 07/13/2009 |
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: 3deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 06/13/2009date Of Correction: 07/13/2009 |
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: Provide Housekeeping And Maintenance Services.survey Date: 06/13/2009date Of Correction: 07/13/2009 |
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: Somelevel Of Harm: 2deficiency: Keep Each Resident's Personal And Medical Records Private And Confidential.survey Date: 06/13/2009date Of Correction: 07/13/2009 |
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: 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: 06/13/2009date Of Correction: 07/13/2009 |
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: Somelevel Of Harm: 3deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 06/13/2009date Of Correction: 07/13/2009 |
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: Somelevel Of Harm: 3deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.survey Date: 06/13/2009date Of Correction: 07/13/2009 |
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: 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: 03/04/2010date Of Correction: 03/31/2010 |
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: Somelevel Of Harm: 2deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan.survey Date: 06/13/2009date Of Correction: 07/13/2009 |
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: Somelevel Of Harm: 2deficiency: Train All Employees On What To Do In An Emergency, And Carry Out Announced Staff Drills.survey Date: 06/13/2009date Of Correction: 07/17/2009 |
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: 06/13/2009date Of Correction: 07/20/2009 |
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: Somelevel Of Harm: 2deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.survey Date: 06/13/2009date Of Correction: 07/13/2009 |
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 |
|
23.3 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 8.9 / 9.9 |
1.9 % |
| Percent of long-stay residents who self-report moderate to severe pain |
|
11.3 % |
| Percent of long-stay high-risk residents with pressure ulcers |
|
6.8 % |
| Percent of long-stay residents who lose too much weight |
|
6 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
|
20 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
|
10.7:1 |
| Percent of long-stay residents with a urinary tract infection |
|
6.8 % |
| Percent of long-stay residents who have depressive symptoms |
|
9.1 % |
| Percent of long-stay residents who were physically restrained |
|
13.3 % |
| Percent of short-stay residents who self-report moderate to severe pain |
|
27.3 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 84.4 % |
77.6 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 83.3 % |
79.6 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 27.3 % |
7.7 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
|
0.8 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
|
22.4:1 |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 8.2 % |
3.8 % |
| Percent of long-stay residents who self-report moderate to severe pain |
|
11.1 % |
| Percent of long-stay high-risk residents with pressure ulcers |
|
8.1 / 8.8 |
| Percent of long-stay residents who lose too much weight |
| 22.6 % |
7.5 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
|
20.4 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
|
9.3 % |
| Percent of long-stay residents with a urinary tract infection |
| 38.7 % |
7.5 % |
| Percent of long-stay residents who have depressive symptoms |
| 27.3 % |
7 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
13 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 3 % |
1.6 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 29.6 % |
22.6 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 88.9 % |
56.9 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 90 % |
59.7 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 12.7 % |
18.3 % |