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TRINITY MISSION HEALTH & REHAB OF COMFORT

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TRINITY MISSION HEALTH & REHAB OF COMFORT VS
Nursing Homes USA
General
City COMFORT   0% Nursing Homes USA have COMFORT
State attribute explanation TX   7.6% Nursing Homes USA have TX
Street 615 FALTIN AVE  
Zip Code 78013  
Phone 8309953747  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
76 
108.94
Total Number of Residents
66 
91.25
Percent of Occupied Beds
87 %
83.65 %
Health Survey Date 8/9/2011  
Fire Survey Date 8/2/2011  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? No  68.7% Nursing Homes USA don't have Quality Indicator Survey?
Special Focus Facility? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
58.16
Total Enforcement Actions Count
56.31
# of deficiencies
7.48
Staff Information
Number of Residents
66 
91.38
Number of RN Hours Per Resident Per Day
0.19 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.92 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.11 
1.59
Number of CNA Hours Per Resident Per Day
0.08 
5.49
Number Therapy Hours Per Resident Per Day
0.08 
0.10
Resident Rights Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Keep Each Resident's Personal And Medical Records Private And Confidential.
survey Date: 04/06/2012
date Of Correction: 05/01/2012 
Resident Assessment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Make Sure That Doctors See A Resident's Plan Of Care At Every Visit And Make Notes About Progress And Orders In Writing.
survey Date: 04/06/2012
date Of Correction: 05/01/2012 
Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Keep Complete, Dated Lab Records In The Resident's File.
survey Date: 04/06/2012
date Of Correction: 05/01/2012 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Quickly Tell The Resident's Doctor The Results Of Lab Tests.
survey Date: 04/06/2012
date Of Correction: 05/01/2012 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
35.7 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain
4.9 %
16.66 %
Percent of long-stay high-risk residents with pressure ulcers
2.9 %
12.58 %
Percent of long-stay residents who lose too much weight
3.3 %
11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.6 %
15.63 %
Percent of long-stay residents with a urinary tract infection
13.8 %
13.46 %
Percent of long-stay residents who have depressive symptoms
26.7 %
28.38 %
Percent of long-stay residents who were physically restrained
75.2 %
43.68 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
75 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
73.9 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
75.2 
45.90
Percent of long-stay residents experiencing one or more falls with major injury
4.9 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
34.7 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
4 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
5.2 %
9.22 %
Percent of long-stay residents who lose too much weight
7.7 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
33.8 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
4.3 %
10.65 %
Percent of long-stay residents with a urinary tract infection
8.4 %
9.58 %
Percent of long-stay residents who have depressive symptoms
20 %
19.86 %
Percent of long-stay residents who were physically restrained
75.2 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
4.4 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
11.3 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
56.4 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
22.1 (71.8) %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
5.3 %
17.34 %

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