CEDAR CREEK NURSING AND REHABILITATION CENTER

Nursing Home Inspector

159 MONTAGUE AVE
BANDERA, TX 78003
Bandera County
Phone: 830-460-3767
Provider Number: 675929
Last Inspection: 11/04/2016

About the Nursing Home

Number of Beds: 62
Number of Residents: 34
Beds Available: 28
Percent Occupancy: 55%
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

 

9

Facility
47

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

9

2016
10

2015
21

2014

Medicare Ratings

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

 

Details by Inspection Date

11/4/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 12/16/2016
 
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 12/16/2016
 

9/17/2015 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 9/21/2015
 
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 9/21/2015
 

6/27/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure the activities program is directed by a qualified professional. Widespread : Potential 4 7/16/2014
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 6/28/2014
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/28/2014
 
Failed To: Dispose of garbage and refuse properly. Widespread : Potential 4 6/28/2014
 
Failed To: Ensure laboratory services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or have an agreement to obtain services from an offsite laboratory, that meets the same requirements. Pattern : Minimal 4 7/15/2014
 

Complaint Investigation Deficiencies

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

2/23/2017 Investigation

 
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 2/24/2017
 
Failed To: Ensure 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. Pattern : Minimal 4 2/24/2017
 

12/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Pattern : Immediate 6 12/15/2016
 
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. Pattern : Immediate 6 12/15/2016
 
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. Pattern : Immediate 6 12/15/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Immediate 6 12/15/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Immediate 6 12/15/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Pattern : Minimal 4 12/15/2016
 

7/19/2016 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 : Minimal 4 7/21/2016
 

2/5/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide residents with private access to a telephone. Pattern : Potential 3 unknown
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 34 58.00 75.11
Registered Nurses 0.76 0.70 0.59
Licensed Practical / Vocational Nurses 0.70 0.83 0.94
Certified Nursing Assistants 2.27 1.67 2.20
Total Staff Hours 3.73 3.20 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 20 13 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 99 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 98 92
of long-stay residents experiencing one or more falls with major injury 5 6 3
of long-stay residents who have depressive symptoms 2 1 3
of long-stay residents who lose too much weight 1 5 5
of long-stay residents who received an antianxiety or hypnotic medication 30 28 26
of long-stay residents who received an antipsychotic medication 18 13 17
of long-stay residents who self-report moderate to severe pain 1 3 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 12 15 20
of long-stay residents whose need for help with daily activities has increased 7 11 18
of long-stay residents with a catheter inserted and left in their bladder 0 0 2
of long-stay residents with a urinary tract infection 2 3 3
of low risk long-stay residents who lose control of their bowels or bladder 28 35 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 100 99 77
of short-stay residents who had an outpatient emergency department visit 10 8 13
of short-stay residents who newly received an antipsychotic medication 0 53 59
of short-stay residents who self-report moderate to severe pain 0 0 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 93 3 12
of short-stay residents who were rehospitalized after a nursing home admission 23 89 74
of short-stay residents with pressure ulcers that are new or worsened 1 26 23