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West Oaks Nursing & Rehab Center

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About West Oaks Nursing & Rehab Center

General Information

Legal Business NameWest Oaks Scc LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareFebruary 24, 1995 (22 years)
Capacity136
Residents104
Percent Occupied76%
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 West Oaks Nursing & Rehab Center

West Oaks Nursing & Rehab Center
was reviewed by Medicare to have a rating of 1 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

June 30, 2016 - 9 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionTry to resolve each resident's complaints quickly.
FManyPotential for HarmHealth InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
FManyPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
FManyPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FManyPotential for HarmHealth InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
FManyPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
FManyPotential for HarmHealth InspectionPost nurse staffing information/data on a daily basis.
ESomePotential for HarmHealth InspectionProvide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture.
ESomePotential for HarmHealth InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmHealth InspectionReasonably accommodate the needs and preferences of each resident.
ESomePotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

April 14, 2016 - 11 months ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$28,488 fine
KSomeImmediate JeopardyComplaintMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
KSomeImmediate JeopardyComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
KSomeImmediate JeopardyComplaintProtect each resident from mistreatment, neglect and misappropriation of personal property.
KSomeImmediate JeopardyComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

November 17, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
ESomePotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

September 8, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmComplaintTry to resolve each resident's complaints quickly.

July 16, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
HSomeActual HarmComplaint+InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
HSomeActual HarmHealth InspectionEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.
FManyPotential for HarmComplaint+InspectionProvide care by qualified persons according to each resident's written plan of care.
FManyPotential for HarmComplaint+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.
FManyPotential for HarmHealth InspectionGive or get quality laboratory services/tests in a timely manner to meet the needs of residents.
FManyPotential for HarmHealth InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
FManyPotential for HarmHealth InspectionMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards.
FManyPotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmComplaint+InspectionMake sure that special or therapeutic diets are ordered by the attending doctor.
ESomePotential for HarmComplaint+InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
ESomePotential for HarmComplaint+InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmComplaint+InspectionMake sure that nurse aides show they have the skills and techniques to be able to care for residents' needs.
ESomePotential for HarmComplaint+InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
ESomePotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmHealth InspectionEnsure services provided by the nursing facility meet professional standards of quality.
ESomePotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
ESomePotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
ESomePotential for HarmHealth 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 HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
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 InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
ESomePotential for HarmHealth InspectionEnsure residents maintain acceptable nutritional status.
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.

June 23, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$40,950 fine
---Payment DenialPayment denial for 54 days
ESomePotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

April 21, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintEnsure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion.

April 6, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintQuickly tell the resident's doctor the results of laboratory tests.
DFewPotential for HarmComplaintGive 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.
DFewPotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.
DFewPotential for HarmComplaintDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaintProvide written records when a resident is transferred or discharged.

February 25, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 33 days
ESomePotential for HarmComplaintHave enough nurses to care for every resident in a way that maximizes the resident's well being.

January 7, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintHelp and prepare each resident for a safe and easy discharge or transfer from the nursing home.

December 23, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

September 4, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaint+InspectionProvide care by qualified persons according to each resident's written plan of care.
ESomePotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaint1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.

August 21, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmComplaint+InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmComplaint+InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
ESomePotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmComplaint+InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaint+InspectionImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
DFewPotential for HarmComplaint+InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
DFewPotential for HarmComplaint+InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmComplaint+InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

May 29, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of West Oaks Nursing & Rehab Center 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.

1hr 60min
2hr 45min
ReportedExpected
CNA
45min
55min
ReportedExpected
LPN
35min
1hr 30min
ReportedExpected
RN
3hr 15min
5hr 10min
ReportedExpected
Total Nursing

This facility also provides approximately 45min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

71.0%
84.7%
84.7%
84.7%
91.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
35.4%
27.9%
41.1%
51.0%
89.8%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
84.2%
93.2%
95.5%
93.9%
48.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of low risk long-stay residents who lose control of their bowels or bladder
21.5%
28.3%
27.2%
26.3%
27.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antianxiety or hypnotic medication
30.3%
24.8%
29.4%
27.5%
20.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose ability to move independently worsened
16.9%
18.1%
16.3%
14.1%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antipsychotic medication
21.0%
22.1%
18.0%
7.2%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose need for help with daily activities has increased
2.4%
1.1%
1.2%
1.1%
7.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who self-report moderate to severe pain
10.5%
12.0%
21.5%
12.5%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who lose too much weight
6.8%
10.2%
4.6%
9.8%
6.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of high risk long-stay residents with pressure ulcers
0.0%
0.0%
0.0%
0.0%
4.9%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who have depressive symptoms
1.1%
2.0%
0.0%
0.0%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a urinary tract infection
2.1%
1.0%
1.1%
4.2%
3.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents experiencing one or more falls with major injury
4.4%
4.0%
0.0%
1.4%
2.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

2.8%
1.7%
10.0%
11.6%
74.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
14.1%
21.7%
21.7%
21.7%
71.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
55.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
4.5%
2.9%
2.4%
0.0%
14.2%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who self-report moderate to severe pain
4.8%
8.3%
9.7%
4.8%
3.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
0.9%
0.9%
0.0%
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents with pressure ulcers that are new or worsened