TLC WEST NURSING AND REHABILITATION Nursing Home


TLC WEST NURSING AND REHABILITATION (CCN: 455522) is a For profit - Limited Liability company facility located in TEMPLE, TX (76502). The facility has an overall rating of 3/5, health inspection rating of 3/5, and a staffing rating of 1/5. It offers 104 certified beds and maintains an average of 46.1 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 2.54830 total hours per resident per day. It has been certified since May 29, 1985 and the last listed health inspection was on June 9, 2022, The facility is located in Bell county and provides senior and nursing home care.

TLC WEST NURSING AND REHABILITATION Summary


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Provider Name: TLC WEST NURSING AND REHABILITATION

Address: 1700 MARLANDWOOD RD, TEMPLE, TX 76502

Phone: (254) 743-6200

County: Bell (120)

Ownership Type: For profit - Limited Liability company

Certified Beds: 104

Average Residents Per Day: 46.1 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: CARADAY TEMPLE WEST LLC

First Approved Date: May 29, 1985

Affiliated Entity: CARADAY HEALTHCARE (103)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 3 ()

Health Inspection Rating: 3 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 1 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.34112, LPN Staff Hours Per Day: 0.6086, RN Staff Hours Per Day: 0.5985, Licensed Staff Hours Per Day: 1.2071

Total Nurse Staff Hours Per Day, per resident: 2.54830

Weekend Nurse Staff Hours: 2.16188, Weekend RN Staff Hours: 0.4570

PT Staff Hours Per Day, per resident: 0.0174

Nurse Staff Turnover: 53.1, Nurse Turnover Note:

RN Turnover: 57.1, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.0520, Case Mix LPN Hours Per Day: 0.8713, Case Mix RN Hours Per Day: 0.5516

Adjusted Nurse Aide Hours Per Day, per resident: 1.33144, Adjusted LPN Hours Per Day: 0.5155, Adjusted RN Hours Per Day: 0.4088

Total Adjusted Nurse Hours Per Day, per resident: 2.31141

Adjusted Weekend Nurse Hours Per Day, per resident: 1.96091

Health Survey Dates and Scores: Cycle 1: 2022-06-09 (Score: 16), Cycle 2: 2019-09-12 (Score: 24), Cycle 3: 2018-08-30 (Score: 144)

Total Weighted Health Score: 40.000

Reported Incidents: 0, Substantiated Complaints: 1

Infection Control Citations: 0

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 45985.00, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 1700 MARLANDWOOD RD,TEMPLE,TX,76502 (31.0652, -97.372)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-11-14

Type: Health, Deficiency: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-18

Citation on 2023-11-14

Type: Health, Deficiency: Respond appropriately to all alleged violations.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-12-18

Citation on 2022-06-09

Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-21

Citation on 2022-06-09

Type: Health, Deficiency: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-21

Citation on 2019-09-12

Type: Health, Deficiency: Assure that each resident’s assessment is updated at least once every 3 months.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-05

Citation on 2019-09-12

Type: Health, Deficiency: Provide and implement an infection prevention and control program.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-05

Citation on 2019-09-12

Type: Health, Deficiency: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-05

Citation on 2021-12-15

Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-12-23

Citation on 2021-10-09

Type: Health, Deficiency: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Severity: K - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-10-10

Citation on 2018-08-30

Type: Health, Deficiency: Provide care and assistance to perform activities of daily living for any resident who is unable.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-09-28

Citation on 2018-08-30

Type: Health, Deficiency: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-09-28

Citation on 2018-08-30

Type: Health, Deficiency: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-09-28

Citation on 2018-08-30

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-09-28


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-04-07

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-28

Citation on 2023-04-07

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-04-28

Citation on 2019-09-10

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-05

Citation on 2019-09-10

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has no plan of correction on

Citation on 2019-09-10

Type: Fire Safety, Tag: 0741, Version: New

Description: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-05

Citation on 2019-09-10

Type: Fire Safety, Tag: 0918, Version: New

Description: Have generator or other power source capable of supplying service within 10 seconds.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2019-10-05

Citation on 2018-09-07

Type: Fire Safety, Tag: 0344, Version: New

Description: Have an alternate power supply for its alarm system.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-01

Citation on 2018-09-07

Type: Fire Safety, Tag: 0351, Version: New

Description: Install an approved automatic sprinkler system.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-01

Citation on 2018-09-07

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-01

Citation on 2018-09-07

Type: Fire Safety, Tag: 0712, Version: New

Description: Have simulated fire drills held at unexpected times.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2018-10-01