WESTRIDGE NURSING AND REHABILITATION LP

Nursing Home Inspector

1241 WESTRIDGE AVE
LANCASTER, TX 75146
Dallas County
Phone: 972-227-5110
Provider Number: 675809
Last Inspection: 03/09/2017

About the Nursing Home

Number of Beds: 110
Number of Residents: 64
Beds Available: 46
Percent Occupancy: 58%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
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

 

13

Facility
11

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

13

2017
26

2016
21

2015

Medicare Ratings

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

 

Details by Inspection Date

3/9/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Pattern : Minimal 4 3/28/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 3/28/2017
 
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 3/29/2017
 

4/29/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 6/4/2016
 
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Pattern : Minimal 4 6/4/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 6/4/2016
 
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 6/4/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/4/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 6/4/2016
 

3/6/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide residents with private access to a telephone. Pattern : Minimal 4 4/6/2015
 
Failed To: Provide activities to meet the interests and needs of each resident. Pattern : Minimal 4 4/6/2015
 
Failed To: Maintain 15 months of resident assessments in the resident's active clinical record. Pattern : Minimal 4 4/6/2015
 
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 4/6/2015
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 4/6/2015
 

Complaint Investigation Deficiencies

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

6/1/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Pattern : Minimal 4 7/12/2017
 

2/6/2017 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 3/9/2017
 
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 3/9/2017
 

7/28/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Immediate 6 7/31/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 64 84.23 75.11
Registered Nurses 0.39 0.65 0.59
Licensed Practical / Vocational Nurses 1.47 0.88 0.94
Certified Nursing Assistants 2.11 2.14 2.20
Total Staff Hours 3.98 3.68 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 7 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 94 91 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 88 92
of long-stay residents experiencing one or more falls with major injury 4 2 3
of long-stay residents who have depressive symptoms 0 3 3
of long-stay residents who lose too much weight 0 4 5
of long-stay residents who received an antianxiety or hypnotic medication 43 20 26
of long-stay residents who received an antipsychotic medication 50 15 17
of long-stay residents who self-report moderate to severe pain 3 2 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 24 22 20
of long-stay residents whose need for help with daily activities has increased 20 19 18
of long-stay residents with a catheter inserted and left in their bladder 1 2 2
of long-stay residents with a urinary tract infection 0 2 3
of low risk long-stay residents who lose control of their bowels or bladder 36 53 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 42 77 77
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 50 12 13
of short-stay residents with pressure ulcers that are new or worsened 0 53 59