Provider Name: WILLOW SPRINGS HEALTH & REHABILITATION CENTER
Address: 4934 S 7TH ST, ABILENE, TX 79605
Phone: (325) 692-2172
County: Taylor (911)
Ownership Type: For profit - Corporation
Certified Beds: 96
Average Residents Per Day: 47.6 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: CHILDRESS COUNTY HOSPITAL DISTRICT
First Approved Date: May 20, 1994
Affiliated Entity: FUNDAMENTAL HEALTHCARE (231)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: None
Sprinkler System Status: Yes
Overall Rating: 2 ()
Health Inspection Rating: 3 ()
QM Rating: 4 ()
Long Stay QM Rating: 4 ()
Short Stay QM Rating: 3 ()
Staffing Rating: 1 (12)
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.14197, LPN Staff Hours Per Day: 0.7067, RN Staff Hours Per Day: 0.2681, Licensed Staff Hours Per Day: 0.9748
Total Nurse Staff Hours Per Day, per resident: 2.11678
Weekend Nurse Staff Hours: 1.90234, Weekend RN Staff Hours: 0.2080
PT Staff Hours Per Day, per resident: 0.0088
Nurse Staff Turnover: 71.2, Nurse Turnover Note:
RN Turnover: 90.0, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 1.9413, Case Mix LPN Hours Per Day: 0.7598, Case Mix RN Hours Per Day: 0.3812
Adjusted Nurse Aide Hours Per Day, per resident: 1.19839, Adjusted LPN Hours Per Day: 0.6863, Adjusted RN Hours Per Day: 0.2650
Total Adjusted Nurse Hours Per Day, per resident: 2.16462
Adjusted Weekend Nurse Hours Per Day, per resident: 1.94533
Health Survey Dates and Scores: Cycle 1: 2022-11-10 (Score: 56), Cycle 2: 2021-09-17 (Score: 36), Cycle 3: 2019-09-26 (Score: 20)
Total Weighted Health Score: 43.333
Reported Incidents: 5, Substantiated Complaints: 4
Infection Control Citations: 2
Fines and Penalties: Number of Fines: 3, Total Fines in Dollars: 15407.80, Payment Denials Number: 0, Total Penalties Number: 3
Location and GPS: 4934 S 7TH ST,ABILENE,TX,79605 (32.4439, -99.785)
Process Date: 2024-03-01
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:
Type: Health, Deficiency: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
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 2024-02-07
Type: Health, Deficiency: Provide safe and appropriate respiratory care for a resident when needed.
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 2024-02-07
Type: Health, Deficiency: Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
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 2024-02-07
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 2024-02-07
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
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 2024-02-07
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 2024-02-07
Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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 2023-10-12
Type: Health, Deficiency: Reasonably accommodate the needs and preferences of each resident.
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 2022-12-13
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 2022-12-13
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 2022-12-13
Type: Health, Deficiency: Provide and implement an infection prevention and control program.
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 2022-08-28
Type: Health, Deficiency: Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
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 2022-05-06
Type: Health, Deficiency: Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
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 2021-10-08
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
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 2021-10-08
Type: Health, Deficiency: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
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 2021-10-08
Type: Health, Deficiency: Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
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 2021-10-08
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 2021-10-08
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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 2021-03-11
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 2019-10-11
Type: Health, Deficiency: Develop and implement policies and procedures for flu and pneumonia vaccinations.
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 2019-10-11
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:
Type: Fire Safety, Tag: 0026, Version: New
Description: Establish roles under a Waiver declared by secretary.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-06
Type: Fire Safety, Tag: 0712, Version: New
Description: Have simulated fire drills held at unexpected times.
Severity: C - Level 1: No actual harm with potential for minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2023-01-06
Type: Fire Safety, Tag: 0222, Version: New
Description: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
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 2021-09-17
Type: Fire Safety, Tag: 0352, Version: New
Description: Properly install and monitor supervisory attachments on automatic sprinkler systems.
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 2021-10-01
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 2019-09-27
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: 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 2019-09-30