Provider Name: SHADY OAK NURSING AND REHABILITATION
Address: 101 S LANCASTER, MOULTON, TX 77975
Phone: (361) 596-7373
County: Lavaca (754)
Ownership Type: Government - Hospital district
Certified Beds: 61
Average Residents Per Day: 34.0 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: WEST WHARTON COUNTY HOSPITAL DISTRICT
First Approved Date: December 10, 1980
Affiliated Entity: CREATIVE SOLUTIONS IN HEALTHCARE (169)
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 2 ()
Health Inspection Rating: 3 ()
QM Rating: 3 ()
Long Stay QM Rating: 4 ()
Short Stay QM Rating: 2 ()
Staffing Rating: 1 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.51265, LPN Staff Hours Per Day: 1.1810, RN Staff Hours Per Day: 0.2726, Licensed Staff Hours Per Day: 1.4537
Total Nurse Staff Hours Per Day, per resident: 2.96639
Weekend Nurse Staff Hours: 2.33208, Weekend RN Staff Hours: 0.2842
PT Staff Hours Per Day, per resident: 0.0176
Nurse Staff Turnover: 75.7, Nurse Turnover Note:
RN Turnover: , RN Turnover Note: 6
Admin Left Number: 4, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.1010, Case Mix LPN Hours Per Day: 0.7427, Case Mix RN Hours Per Day: 0.3852
Adjusted Nurse Aide Hours Per Day, per resident: 1.46671, Adjusted LPN Hours Per Day: 1.1734, Adjusted RN Hours Per Day: 0.2667
Total Adjusted Nurse Hours Per Day, per resident: 2.89568
Adjusted Weekend Nurse Hours Per Day, per resident: 2.27648
Health Survey Dates and Scores: Cycle 1: 2023-07-14 (Score: 60), Cycle 2: 2022-06-16 (Score: 8), Cycle 3: 2021-04-07 (Score: 56)
Total Weighted Health Score: 42.000
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 650.00, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 101 S LANCASTER,MOULTON,TX,77975 (29.5741, -97.150)
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: Assure the security of all personal funds of residents deposited with the facility.
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 2023-08-09
Type: Health, Deficiency: Develop and implement policies and procedures to prevent abuse, neglect, and theft.
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 2023-08-09
Type: Health, Deficiency: Assess the resident when there is a significant change in condition
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 2023-08-09
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 2023-08-09
Type: Health, Deficiency: Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
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 2023-08-09
Type: Health, Deficiency: Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement 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 2023-08-09
Type: Health, Deficiency: Provide training in compliance and ethics.
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 2023-08-09
Type: Health, Deficiency: Provide behavior health training consistent with the requirements and as determined by a facility assessment.
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 2023-08-09
Type: Health, Deficiency: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
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 2022-06-17
Type: Health, Deficiency: Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
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 2021-09-16
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 2021-09-16
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 2021-09-16
Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.
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 2021-04-08
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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 2021-04-08
Type: Health, Deficiency: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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 2021-04-08
Type: Health, Deficiency: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.
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 2021-04-08
Type: Health, Deficiency: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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 2021-04-08
Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
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 2021-04-08
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: 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 2023-07-19
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 2023-07-19
Type: Fire Safety, Tag: 0900, Version: New
Description: Meet Health Care Facilities Code mechanical requirements.
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 2023-08-11
Type: Fire Safety, Tag: 0916, Version: New
Description: Have a battery powered remote alarm panel in a location accessible by operating personnel.
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 2023-08-11
Type: Fire Safety, Tag: 0918, Version: New
Description: Have generator or other power source capable of supplying service within 10 seconds.
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 2023-07-19
Type: Fire Safety, Tag: 0004, Version: New
Description: Develop and maintain an Emergency Preparedness Program (EP).
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 2022-06-17
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 2022-06-17
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 2022-06-17
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 2022-06-17