VILLA HAVEN HEALTH AND REHABILITATION CENTER

Nursing Home Inspector

300 S JACKSON ST
BRECKENRIDGE, TX 76424
Stephens County
Phone: 254-559-3386
Provider Number: 675279
Last Inspection: 11/09/2016

About the Nursing Home

Number of Beds: 92
Number of Residents: 37
Beds Available: 55
Percent Occupancy: 40%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
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

 

4

Facility
4

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

4

2016
9

2016
24

2014

Medicare Ratings

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

 

Details by Inspection Date

11/9/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Make 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. Pattern : Minimal 4 12/9/2016
 

1/22/2016 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 2/22/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 2/22/2016
 

10/30/2014 Inspection

 
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 11/25/2014
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 11/25/2014
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 11/25/2014
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 11/25/2014
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 11/25/2014
 

Complaint Investigation Deficiencies

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

6/5/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
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 6/25/2015
 
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 6/25/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 6/25/2015
 
Failed To: Ensure that residents are safe from serious medication errors. Pattern : Immediate 6 6/25/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Immediate 6 6/25/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 37 37.00 75.11
Registered Nurses 0.42 0.42 0.59
Licensed Practical / Vocational Nurses 0.96 0.96 0.94
Certified Nursing Assistants 2.19 2.19 2.20
Total Staff Hours 3.57 3.57 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 1 1 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 99 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 100 100 92
of long-stay residents experiencing one or more falls with major injury 10 10 3
of long-stay residents who have depressive symptoms 1 1 3
of long-stay residents who lose too much weight 7 7 5
of long-stay residents who received an antianxiety or hypnotic medication 45 45 26
of long-stay residents who received an antipsychotic medication 26 26 17
of long-stay residents who self-report moderate to severe pain 3 3 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 15 15 20
of long-stay residents whose need for help with daily activities has increased 19 19 18
of long-stay residents with a catheter inserted and left in their bladder 3 3 2
of long-stay residents with a urinary tract infection 1 1 3
of low risk long-stay residents who lose control of their bowels or bladder 74 74 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 90 90 77
of short-stay residents who had an outpatient emergency department visit 23 23 13
of short-stay residents who made improvements in function 57 57 59
of short-stay residents who newly received an antipsychotic medication 4 4 2
of short-stay residents who self-report moderate to severe pain 8 8 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 94 94 74
of short-stay residents who were rehospitalized after a nursing home admission 11 11 23
of short-stay residents with pressure ulcers that are new or worsened 1 Not Available   46