WESTHAVEN NURSING CENTER

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Texas are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 04/02/2010.

Administration

Train All Employees on What to Do in an Emergency. Inspection Date: 04/02/2010 Correction Date: 04/16/2010

Environmental

Provide Rooms That Are Big Enough for Each Resident. Inspection Date: 08/08/2008 Correction Date: 01/01/1900
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 05/15/2009 Correction Date: 06/01/2009
Provide Rooms That Are Big Enough for Each Resident. Inspection Date: 05/15/2009 Correction Date: 06/01/2009
Provide Rooms That Are Big Enough for Each Resident. Inspection Date: 04/02/2010 Correction Date: 01/01/1900

Mistreatment

Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Inspection Date: 05/15/2009 Correction Date: 06/01/2009

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 08/08/2008 Correction Date: 08/29/2008
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 05/15/2009 Correction Date: 06/01/2009
Make Sure That Residents Are Well Nourished. Inspection Date: 04/02/2010 Correction Date: 04/16/2010
Offer Other Nutritional Food to Each Resident Who Will Not Eat the Food Served. Inspection Date: 04/02/2010 Correction Date: 04/16/2010
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 04/02/2010 Correction Date: 05/14/2010

Pharmacy Service

Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%. Inspection Date: 04/02/2010 Correction Date: 05/14/2010
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 04/02/2010 Correction Date: 05/14/2010

Quality Care

Give or Get Special Rehabilitation if in the Patient's Plan of Care. Inspection Date: 08/08/2008 Correction Date: 08/22/2008

Resident Assessment

Electronically Record and Report Resident Status Assessments in a Timely Manner As Required in Order to Monitor Resident Health and Progress. Inspection Date: 08/08/2008 Correction Date: 08/09/2008

Resident Rights

Keep Each Resident's Personal and Medical Records Private and Confidential. Inspection Date: 08/08/2008 Correction Date: 09/26/2008
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 08/08/2008 Correction Date: 09/26/2008

The table below lists incident reports by the nursing staff or administration for Westhaven Nursing Center, as well as complaints by residents or their family in the previous three years.

Administration

Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents. Complaint Filed: 08/08/2008 Correction Date: 09/30/2008

Environmental

Have a Program to Keep Infection from Spreading. Complaint Filed: 08/08/2008 Correction Date: 09/30/2008

Mistreatment

1) Hire Only People Who Have 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. Complaint Filed: 02/18/2010 Correction Date: 04/05/2010
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Complaint Filed: 02/18/2010 Correction Date: 04/05/2010
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property. Complaint Filed: 01/20/2011 Correction Date: 03/01/2011
1) Hire Only People Who Have 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. Complaint Filed: 01/20/2011 Correction Date: 03/01/2011

Pharmacy Service

Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Complaint Filed: 08/08/2008 Correction Date: 09/30/2008

Quality Care

Use a Registered Nurse at Least 8 Hours a Day, 7 Days a Week. Complaint Filed: 09/03/2010 Correction Date: 10/10/2010

Resident Assessment

Do a New Assessment After Any Major Change in a Resident's Physical or Mental Health. Complaint Filed: 02/18/2010 Correction Date: 02/19/2010

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that Westhaven Nursing Center had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 04/01/2010.

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 05/14/2009 Correction Date: 06/15/2009
Portable Fire Extinguishers. Inspection Date: 04/01/2010 Correction Date: 05/14/2010

Building Service Equipment

An Externally Vented Heating System. Inspection Date: 05/14/2009 Correction Date: 06/26/2009
Properly Protected Cooking Facilities. Inspection Date: 05/14/2009 Correction Date: 06/01/2009
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions. Inspection Date: 04/01/2010 Correction Date: 01/01/1900
Properly Protected Cooking Facilities. Inspection Date: 04/01/2010 Correction Date: 05/14/2010

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke. Inspection Date: 04/01/2010 Correction Date: 05/01/2010

Electrical

Weekly Inspections and Monthly Testing of Generators. Inspection Date: 05/14/2009 Correction Date: 06/26/2009
Properly Installed Electrical Wiring and Equipment. Inspection Date: 05/14/2009 Correction Date: 06/01/2009

Exits and Egress

Exits That Are Accessible at All Times. Inspection Date: 04/01/2010 Correction Date: 05/01/2010

Fire Alarm Systems

A Fire Alarm System That Can Be Heard Throughout the Facility. Inspection Date: 04/01/2010 Correction Date: 05/14/2010

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 08/07/2008 Correction Date: 08/22/2008
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 04/01/2010 Correction Date: 05/14/2010

Smoke Compartmentation and Control

Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes. Inspection Date: 08/07/2008 Correction Date: 09/08/2008
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour. Inspection Date: 05/14/2009 Correction Date: 06/01/2009
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes. Inspection Date: 05/14/2009 Correction Date: 06/08/2009

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed. Inspection Date: 05/14/2009 Correction Date: 06/12/2009