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The Melrose

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About The Melrose

General Information

Legal Business NameNorthcreek Healthcare LLC
Ownership TypeFor Profit - Individual
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareSeptember 4, 2014 (2 years)
Capacity90
Residents36
Percent Occupied40%
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 The Melrose

The Melrose
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 2 Years

Note that this facility has only accepted Medicare for 2 years.
The state and national averages include problems for 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

July 31, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
KSomeImmediate JeopardyComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

July 9, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionProperly protected cooking facilities.
FManyPotential for HarmFire Safety InspectionWeekly inspections and monthly testing of generators.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
CManyPotential for Minimal HarmFire Safety InspectionA fire alarm system that can be heard throughout the facility.
CManyPotential for Minimal HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
CManyPotential for Minimal HarmFire Safety InspectionProper backup exit lighting.
CManyPotential for Minimal HarmFire Safety InspectionExits that are accessible at all times.
BSomePotential for Minimal HarmFire Safety InspectionProperly installed hallway dispensers for alcohol-based hand rub.

July 8, 2015 - 17 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
FManyPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
FManyPotential for HarmHealth InspectionMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FManyPotential 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 InspectionKeep all essential equipment working safely.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionMake sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed.
ESomePotential for HarmHealth InspectionProvide food in a way that meets a resident's needs.
ESomePotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.

March 19, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

July 18, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionHeating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FManyPotential for HarmFire Safety InspectionProper medical gas storage and administration areas.
FManyPotential for HarmFire Safety InspectionProperly installed hallway dispensers for alcohol-based hand rub.
FManyPotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
FManyPotential for HarmFire Safety InspectionPortable fire extinguishers.
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
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 InspectionExits that are accessible at all times.
CManyPotential for Minimal HarmFire Safety InspectionWeekly inspections and monthly testing of generators.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of The Melrose 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.

3hr 10min
2hr 10min
ReportedExpected
CNA
1hr 15min
30min
ReportedExpected
LPN
25min
45min
ReportedExpected
RN
4hr 50min
3hr 25min
ReportedExpected
Total Nursing

This facility also provides approximately 5min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

100.0%
100.0%
100.0%
90.7%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
94.4%
83.8%
87.9%
Q1 2015Q2 2015Q3 2015TX
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
46.9%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
-
-
-
22.3%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Received an Antipsychotic Medication
-
-
-
19.6%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Need for Help with ADLs has Increased
0.0%
0.0%
-
8.8%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
2.7%
5.6%
2.9%
6.3%
Q1 2015Q2 2015Q3 2015TX
Lose Too Much Weight
-
-
-
6.6%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
High Risk Residents With Pressure Ulcers
10.3%
8.6%
2.7%
6.1%
Q1 2015Q2 2015Q3 2015TX
Have Depressive Symptoms
2.7%
5.6%
11.4%
5.1%
Q1 2015Q2 2015Q3 2015TX
With a Urinary Tract Infection
2.6%
0.0%
0.0%
3.5%
Q1 2015Q2 2015Q3 2015TX
Experiencing One or More Falls with Major Injury
3.1%
0.0%
0.0%
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

-
-
-
71.4%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
71.1%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
-
-
-
16.5%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Self Report Moderate to Severe Pain
-
-
-
3.2%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
Newly Received an Antipsychotic Medication
-
-
-
1.0%
Q1 2015Q2 2015Q3 2015TX
* The data for this facility for some quarters is unavailable.
With Pressure Ulcers That Are New or Worsened