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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
Residents108
Percent Occupied81%
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 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

October 24, 2016 - 9 months ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 3 days
FManyPotential for HarmHealth InspectionTrain all employees on what to do in an emergency, and carry out unannounced staff drills.
FManyPotential for HarmHealth InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
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 Inspection1) 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.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
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 InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
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 InspectionProvide activities to meet the interests and needs of each resident.
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.

December 10, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$5,525 fine
KSomeImmediate JeopardyComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

September 25, 2015 - 2 years 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.

August 22, 2014 - 3 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.

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 15min
ReportedExpected
CNA
30min
35min
ReportedExpected
LPN
25min
1hr 10min
ReportedExpected
RN
3hr 15min
4hr 5min
ReportedExpected
Total Nursing

This facility also provides approximately 20min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

87.2%
99.0%
99.0%
99.0%
91.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
94.9%
99.0%
100.0%
100.0%
89.8%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
39.0%
52.6%
55.6%
48.8%
48.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of low risk long-stay residents who lose control of their bowels or bladder
17.4%
15.4%
18.7%
20.0%
27.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antianxiety or hypnotic medication
21.7%
9.2%
7.2%
7.2%
20.7%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose ability to move independently worsened
36.3%
33.0%
32.2%
30.1%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who received an antipsychotic medication
22.7%
16.5%
18.2%
20.9%
19.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents whose need for help with daily activities has increased
10.4%
3.8%
0.0%
0.0%
7.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who self-report moderate to severe pain
0.0%
0.0%
6.3%
8.2%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who lose too much weight
8.9%
8.8%
1.8%
0.0%
6.3%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of high risk long-stay residents with pressure ulcers
2.2%
0.0%
0.0%
0.0%
4.9%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents who have depressive symptoms
0.0%
1.0%
4.2%
2.0%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents with a urinary tract infection
2.0%
1.0%
1.0%
1.0%
3.6%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of long-stay residents experiencing one or more falls with major injury
4.5%
1.8%
1.4%
1.8%
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

62.5%
73.2%
95.3%
97.4%
74.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
22.2%
90.2%
90.2%
90.2%
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
20.0%
13.8%
12.9%
8.7%
14.2%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents who self-report moderate to severe pain
0.0%
0.0%
0.0%
-
3.1%
Q4 2015Q1 2016Q2 2016Q3 2016TX
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
0.0%
0.0%
0.0%
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016TX
Percentage of short-stay residents with pressure ulcers that are new or worsened