FOCUSED CARE OF WAXAHACHIE

Nursing Home Inspector

1413 W MAIN ST
WAXAHACHIE, TX 75165
Ellis County
Phone: 972-937-2298
Provider Number: 455591
Last Inspection: 05/25/2017

About the Nursing Home

Number of Beds: 152
Number of Residents: 61
Beds Available: 91
Percent Occupancy: 40%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Individual
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

24

Facility
13

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

24

2017
21

2016
35

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

5/25/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 7/9/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 7/9/2017
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Widespread : Potential 4 7/9/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Widespread : Minimal 5 7/9/2017
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Widespread : Minimal 5 7/9/2017
 

4/14/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep all essential equipment working safely. Pattern : Minimal 4 4/15/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Minimal 4 5/14/2016
 
Failed To: Conduct initial and periodic assessments of each resident's functional capacity. Widespread : Minimal 5 5/14/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 5/14/2016
 
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Pattern : Minimal 4 4/14/2016
 

4/17/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Pattern : Potential 3 5/13/2015
 
Failed To: 1) 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. Widespread : Minimal 5 5/13/2015
 
Failed To: Ensure 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. Pattern : Minimal 4 5/13/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Actual 5 5/13/2015
 
Failed To: Develop 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. Widespread : Minimal 5 5/13/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Pattern : Minimal 4 5/13/2015
 
Failed To: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Widespread : Minimal 5 5/13/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 5/13/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/10/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Widespread : Minimal 5 4/11/2017
 

2/10/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Widespread : Minimal 5 3/2/2017
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 61 72.56 75.11
Registered Nurses 0.98 0.59 0.59
Licensed Practical / Vocational Nurses 0.99 0.83 0.94
Certified Nursing Assistants 2.42 2.32 2.20
Total Staff Hours 4.39 3.74 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 11 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 90 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 84 92
of long-stay residents experiencing one or more falls with major injury 4 3 3
of long-stay residents who have depressive symptoms 3 6 3
of long-stay residents who lose too much weight 4 5 5
of long-stay residents who received an antianxiety or hypnotic medication 25 26 26
of long-stay residents who received an antipsychotic medication 41 16 17
of long-stay residents who self-report moderate to severe pain 0 4 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 24 23 20
of long-stay residents whose need for help with daily activities has increased 23 22 18
of long-stay residents with a catheter inserted and left in their bladder 2 1 2
of long-stay residents with a urinary tract infection 0 3 3
of low risk long-stay residents who lose control of their bowels or bladder 42 43 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 98 71 77
of short-stay residents who had an outpatient emergency department visit 24 16 13
of short-stay residents who made improvements in function 70 63 59
of short-stay residents who newly received an antipsychotic medication 5 3 2
of short-stay residents who self-report moderate to severe pain 0 11 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 72 64 74
of short-stay residents who were rehospitalized after a nursing home admission 20 23 23
of short-stay residents who were successfully discharged to the community 35 49 46
of short-stay residents with pressure ulcers that are new or worsened 1 0 0