Provider Name: THE BRAZOS OF WACO
Address: 2430 MARKET PLACE DRIVE, WACO, TX 76711
Phone: (254) 981-7900
County: Mc Lennan (780)
Ownership Type: For profit - Corporation
Certified Beds: 123
Average Residents Per Day: 56.6 ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: CITY OF ENNIS
First Approved Date: November 2, 2016
Affiliated Entity: FUNDAMENTAL HEALTHCARE (231)
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: 2 ()
Long Stay QM Rating: 2 ()
Short Stay QM Rating: 2 ()
Staffing Rating: 1 (12)
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 1.88566, LPN Staff Hours Per Day: 1.1155, RN Staff Hours Per Day: 0.1661, Licensed Staff Hours Per Day: 1.2817
Total Nurse Staff Hours Per Day, per resident: 3.16739
Weekend Nurse Staff Hours: 2.79849, Weekend RN Staff Hours: 0.1908
PT Staff Hours Per Day, per resident: 0.0231
Nurse Staff Turnover: 66.7, Nurse Turnover Note:
RN Turnover: 83.3, RN Turnover Note:
Admin Left Number: 2, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.0800, Case Mix LPN Hours Per Day: 0.7420, Case Mix RN Hours Per Day: 0.3405
Adjusted Nurse Aide Hours Per Day, per resident: 1.84690, Adjusted LPN Hours Per Day: 1.1094, Adjusted RN Hours Per Day: 0.1838
Total Adjusted Nurse Hours Per Day, per resident: 3.15683
Adjusted Weekend Nurse Hours Per Day, per resident: 2.78916
Health Survey Dates and Scores: Cycle 1: 2023-10-26 (Score: 44), Cycle 2: 2022-09-01 (Score: 48), Cycle 3: 2021-06-24 (Score: 87)
Total Weighted Health Score: 52.500
Reported Incidents: 2, Substantiated Complaints: 6
Infection Control Citations: 2
Fines and Penalties: Number of Fines: 2, Total Fines in Dollars: 54385.50, Payment Denials Number: 0, Total Penalties Number: 2
Location and GPS: 2430 MARKET PLACE DRIVE,WACO,TX,76711 (31.4996, -97.160)
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 2023-09-21
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her 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 2023-07-15
Type: Health, Deficiency: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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 2023-07-15
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: 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 2023-11-16
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 2023-11-16
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 2023-11-16
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 2023-01-26
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 2023-01-26
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 2022-05-27
Type: Health, Deficiency: Assure that each resident’s assessment is updated at least once every 3 months.
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 2022-09-03
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 2022-09-03
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 2022-09-03
Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary drugs.
Severity: J - Level 4: Immediate jeopardy to resident health or safety. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2021-12-02
Type: Health, Deficiency: Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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 2021-09-10
Type: Health, Deficiency: Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
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 2021-08-14
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: