CAPSTONE HEALTHCARE ESTATES ON OREM Nursing Home


CAPSTONE HEALTHCARE ESTATES ON OREM (CCN: 676314) is a For profit - Corporation facility located in HOUSTON, TX (77045). The facility has an overall rating of 2/5, health inspection rating of 2/5, and a staffing rating of 2/5. It offers 120 certified beds and maintains an average of 97.5 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 4.42625 total hours per resident per day. It has been certified since June 7, 2012 and the last listed health inspection was on December 15, 2022, The facility is located in Harris county and provides senior and nursing home care.

CAPSTONE HEALTHCARE ESTATES ON OREM Summary


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Provider Name: CAPSTONE HEALTHCARE ESTATES ON OREM

Address: 3730 W. OREM DRIVE, HOUSTON, TX 77045

Phone: (832) 799-6484

County: Harris (610)

Ownership Type: For profit - Corporation

Certified Beds: 120

Average Residents Per Day: 97.5 ()

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

Legal Business Name: CAPSTONE-HOUSTON OPCO LLC

First Approved Date: June 7, 2012

Affiliated Entity: CAPSTONE MANAGEMENT (102)

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: 2 ()

QM Rating: 4 ()

Long Stay QM Rating: 4 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 2 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.89855, LPN Staff Hours Per Day: 1.0148, RN Staff Hours Per Day: 0.5128, Licensed Staff Hours Per Day: 1.5277

Total Nurse Staff Hours Per Day, per resident: 4.42625

Weekend Nurse Staff Hours: 4.13967, Weekend RN Staff Hours: 0.4927

PT Staff Hours Per Day, per resident: 0.0162

Nurse Staff Turnover: 74.8, Nurse Turnover Note:

RN Turnover: 68.8, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.1362, Case Mix LPN Hours Per Day: 0.8779, Case Mix RN Hours Per Day: 0.4945

Adjusted Nurse Aide Hours Per Day, per resident: 2.76418, Adjusted LPN Hours Per Day: 0.8530, Adjusted RN Hours Per Day: 0.3907

Total Adjusted Nurse Hours Per Day, per resident: 3.97618

Adjusted Weekend Nurse Hours Per Day, per resident: 3.71873

Health Survey Dates and Scores: Cycle 1: 2022-12-15 (Score: 32), Cycle 2: 2021-10-05 (Score: 139), Cycle 3: 2020-01-16 (Score: 28)

Total Weighted Health Score: 67.000

Reported Incidents: 3, Substantiated Complaints: 6

Infection Control Citations: 2

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 50762.24, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 3730 W. OREM DRIVE,HOUSTON,TX,77045 (29.6282, -95.432)

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 2022-12-15

Type: Health, Deficiency: Honor the resident's right to choose his or her attending physician.

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 2023-01-04

Citation on 2022-12-15

Type: Health, Deficiency: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

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 2023-01-04

Citation on 2022-12-15

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 2023-01-04

Citation on 2022-12-15

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: 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 2023-01-04

Citation on 2022-12-15

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 2023-01-04

Citation on 2022-12-15

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 2023-01-04

Citation on 2022-12-15

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

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 2023-01-04

Citation on 2022-10-19

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

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 2022-10-20

Citation on 2022-10-19

Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

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

Corrected: Deficient, Provider has date of correction on 2022-10-20

Citation on 2022-10-19

Type: Health, Deficiency: Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-10-20

Citation on 2021-10-05

Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

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 2021-10-31

Citation on 2021-10-05

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 2021-10-31

Citation on 2021-10-05

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: 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 2021-10-31

Citation on 2021-10-05

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 2021-10-31

Citation on 2021-10-05

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

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 2021-10-31

Citation on 2020-01-16

Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

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 2020-02-12

Citation on 2020-01-16

Type: Health, Deficiency: Ensure each resident receives an accurate assessment.

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 2020-02-12

Citation on 2020-01-16

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: 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 2020-02-12

Citation on 2020-01-16

Type: Health, Deficiency: Ensure that residents are free from significant medication errors.

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 2020-02-12

Citation on 2020-01-16

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 2020-02-12


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 2022-12-15

Type: Fire Safety, Tag: 0211, Version: New

Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.

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 2022-12-22

Citation on 2022-12-15

Type: Fire Safety, Tag: 0511, Version: New

Description: Have properly installed electrical wiring and gas equipment.

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 2022-12-22

Citation on 2022-12-15

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 2022-12-22

Citation on 2022-12-15

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 2022-12-22

Citation on 2021-10-05

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 2021-11-03

Citation on 2021-10-05

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

Description: Install corridor and hallway doors that block smoke.

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 2021-11-03

Citation on 2021-10-05

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 2021-11-03

Citation on 2021-10-05

Type: Fire Safety, Tag: 0929, Version: New

Description: Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

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 2021-11-03

Citation on 2020-01-16

Type: Fire Safety, Tag: 0341, Version: New

Description: Install a fire alarm system that can be heard throughout the facility.

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

Corrected: Deficient, Provider has date of correction on 2020-02-12

Citation on 2020-01-16

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

Description: Inspect, test, and maintain 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 2020-02-12

Citation on 2020-01-16

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

Description: Have simulated fire drills held at unexpected times.

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 2020-02-12

Citation on 2020-01-16

Type: Fire Safety, Tag: 0754, Version: New

Description: Provide properly sized and located linen or trash receptacles.

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 2020-02-12

Citation on 2020-01-16

Type: Fire Safety, Tag: 0916, Version: New

Description: Have a battery powered remote alarm panel in a location accessible by operating personnel.

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 2020-02-12

Citation on 2020-01-16

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

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 2020-02-12