ROCK HAVEN NURSING HOME

Nursing Home Inspector

401 S E STALLINGS DR
NACOGDOCHES, TX 75964
Nacogdoches County
Phone: 936-569-9411
Provider Number: 676340
Last Inspection: 08/02/2017

About the Nursing Home

Number of Beds: 60
Number of Residents: 44
Beds Available: 16
Percent Occupancy: 73%
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

 

5

Facility
18

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

5

2017
52

2016
23

2015

Medicare Ratings

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

 

Details by Inspection Date

8/2/2017 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 8/30/2017
 

9/29/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
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 : Potential 4 10/28/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Pattern : Minimal 4 10/28/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 10/28/2016
 
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 10/28/2016
 
Failed To: Provide food in a way that meets a resident's needs. Pattern : Minimal 4 10/28/2016
 
Failed To: Offer other nutritional food to each resident who will not eat the food served. Widespread : Minimal 5 10/28/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/28/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 10/28/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 10/28/2016
 
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 10/28/2016
 
Failed To: Keep clinical record information safe. Pattern : Minimal 4 10/28/2016
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Widespread : Minimal 5 10/28/2016
 

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 10/9/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 10/9/2015
 
Failed To: Keep all essential equipment working safely. Widespread : Minimal 5 10/9/2015
 
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 10/9/2015
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Widespread : Minimal 5 10/9/2015
 

Complaint Investigation Deficiencies

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

3/24/2017 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 4/14/2017
 

2/18/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Widespread : Minimal 5 3/16/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 44 64.71 75.11
Registered Nurses 0.50 0.55 0.59
Licensed Practical / Vocational Nurses 0.95 0.85 0.94
Certified Nursing Assistants 2.21 2.12 2.20
Total Staff Hours 3.66 3.51 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 14 8 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 84 96 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 94 95 92
of long-stay residents experiencing one or more falls with major injury 5 3 3
of long-stay residents who have depressive symptoms 2 3 3
of long-stay residents who lose too much weight 18 8 5
of long-stay residents who received an antianxiety or hypnotic medication 34 28 26
of long-stay residents who received an antipsychotic medication 32 20 17
of long-stay residents who self-report moderate to severe pain 8 4 5
of long-stay residents who were physically restrained 2 0 0
of long-stay residents whose ability to move independently worsened 14 17 20
of long-stay residents whose need for help with daily activities has increased 22 19 18
of long-stay residents with a catheter inserted and left in their bladder 3 2 2
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 31 33 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 76 90 77
of short-stay residents who had an outpatient emergency department visit 21 14 13
of short-stay residents who made improvements in function 71 47 59
of short-stay residents who newly received an antipsychotic medication 10 2 2
of short-stay residents who self-report moderate to severe pain 29 13 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 61 81 74
of short-stay residents who were rehospitalized after a nursing home admission 21 19 23
of short-stay residents with pressure ulcers that are new or worsened 4 42 46