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Terrace West Nursing And Rehabilitation Lp

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About Terrace West Nursing And Rehabilitation Lp

General Information

Legal Business NameTerrace West Nursing And Rehabilitation Lp
Ownership TypeFor Profit - Partnership
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareMay 21, 1996 (21 years)
Capacity133
Residents98
Percent Occupied74%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Terrace West Nursing And Rehabilitation Lp

Terrace West Nursing And Rehabilitation Lp
was reviewed by Medicare to have a rating of 2 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Texas Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

September 25, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmComplaint+InspectionGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
ESomePotential for HarmComplaint+InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
DFewPotential for HarmHealth InspectionKeep each resident free from physical restraints, unless needed for medical treatment.
BSomePotential for Minimal HarmComplaint+InspectionHonor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States.

September 24, 2015 - 15 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
FManyPotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
ESomePotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.

August 22, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FManyPotential for HarmHealth InspectionHave a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents.
ESomePotential for HarmComplaint+InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmHealth InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
ESomePotential for HarmHealth InspectionProvide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible.
ESomePotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
CManyPotential for Minimal HarmHealth InspectionProvide clean bed and bath linens that are in good condition.

August 21, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionProperly protected cooking facilities.
FManyPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
FManyPotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
FManyPotential for HarmFire Safety InspectionPortable fire extinguishers.
FManyPotential for HarmFire Safety InspectionAn approved installation, maintenance and testing program for fire alarm systems.
FManyPotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
FManyPotential for HarmFire Safety InspectionExits that are accessible at all times.
FManyPotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
ESomePotential for HarmFire Safety InspectionExits that are free from obstructions and can be used at all times.
ESomePotential for HarmFire Safety InspectionPosted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionProperly located and lighted "Exit" signs.

November 5, 2013 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 13 days
---Fine$1,170 fine

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Terrace West Nursing And Rehabilitation Lp require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 15min
2hr 10min
ReportedExpected
CNA
40min
35min
ReportedExpected
LPN
30min
1hr 5min
ReportedExpected
RN
3hr 25min
3hr 50min
ReportedExpected
Total Nursing

This facility also provides approximately 25min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

89.8%
87.2%
87.2%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
79.2%
81.1%
84.7%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
28.6%
44.1%
35.9%
46.9%
Q1 2015Q2 2015Q3 2015TX
Low Risk Residents Who Lose Control of Their Bowel or Bladder
43.6%
40.4%
32.6%
22.3%
Q1 2015Q2 2015Q3 2015TX
Received an Antipsychotic Medication
18.9%
24.4%
21.3%
19.6%
Q1 2015Q2 2015Q3 2015TX
Need for Help with ADLs has Increased
11.7%
12.4%
10.1%
8.8%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
0.0%
1.1%
0.0%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
15.1%
9.1%
5.9%
6.6%
Q1 2015Q2 2015Q3 2015TX
High Risk Residents With Pressure Ulcers
10.1%
4.5%
3.3%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
1.0%
1.1%
0.0%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
2.0%
3.2%
2.0%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
0.7%
1.7%
2.1%
3.3%
Q1 2015Q2 2015Q3 2015TX
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.6%
Q1 2015Q2 2015Q3 2015TX
Were Physically Restrained

Quality Measures for Short Stay Residents

28.6%
21.7%
40.5%
71.4%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
25.8%
22.9%
22.2%
71.1%
Q1 2015Q2 2015Q3 2015TX
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
13.6%
10.7%
8.0%
16.5%
Q1 2015Q2 2015Q3 2015TX
Self Report Moderate to Severe Pain
0.0%
0.0%
0.0%
3.2%
Q1 2015Q2 2015Q3 2015TX
Newly Received an Antipsychotic Medication
3.3%
3.0%
2.7%
1.0%
Q1 2015Q2 2015Q3 2015TX
With Pressure Ulcers That Are New or Worsened