Provider Name: THE WESLEYAN SKILLED NURSING AND REHABILITATION
Address: 4011 WILLIAMS DR, GEORGETOWN, TX 78628
Phone: (512) 868-2700
County: Williamson (970)
Ownership Type: Non profit - Church related
Certified Beds: 142
Average Residents Per Day: 90.4 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: SOUTH LIMESTONE HOSPITAL DISTRICT
First Approved Date: April 26, 2011
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 5 ()
QM Rating: 4 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 4 ()
Staffing Rating: 2 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.62035, LPN Staff Hours Per Day: 1.0125, RN Staff Hours Per Day: 0.3311, Licensed Staff Hours Per Day: 1.3437
Total Nurse Staff Hours Per Day, per resident: 3.96411
Weekend Nurse Staff Hours: 3.43373, Weekend RN Staff Hours: 0.2078
PT Staff Hours Per Day, per resident: 0.0689
Nurse Staff Turnover: 52.5, Nurse Turnover Note:
RN Turnover: 54.5, RN Turnover Note:
Admin Left Number: 1, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.2644, Case Mix LPN Hours Per Day: 0.7375, Case Mix RN Hours Per Day: 0.3547
Adjusted Nurse Aide Hours Per Day, per resident: 2.35748, Adjusted LPN Hours Per Day: 1.0131, Adjusted RN Hours Per Day: 0.3518
Total Adjusted Nurse Hours Per Day, per resident: 3.72244
Adjusted Weekend Nurse Hours Per Day, per resident: 3.22440
Health Survey Dates and Scores: Cycle 1: 2022-12-09 (Score: 8), Cycle 2: 2021-09-29 (Score: 0), Cycle 3: 2019-10-16 (Score: 56)
Total Weighted Health Score: 13.333
Reported Incidents: 0, Substantiated Complaints: 0
Infection Control Citations: 0
Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 1637.85, Payment Denials Number: 0, Total Penalties Number: 2
Location and GPS: 4011 WILLIAMS DR,GEORGETOWN,TX,78628 (30.6738, -97.702)
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: 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 2023-01-13
Type: Health, Deficiency: Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
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 2019-11-08
Type: Health, Deficiency: Ensure each resident receives an accurate 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 2019-11-08
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-11-15
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: 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 2019-11-08
Type: Health, Deficiency: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
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 2019-11-08
Type: Health, Deficiency: Make sure that a working call system is available in each resident's bathroom and bathing area.
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 2019-11-08
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: 0374, Version: New
Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.
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 2021-11-24