WINTERHAVEN HEALTHCARE CENTER (HOUSTON, TX) Detailed Nursing Home Profile

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.340
State:	0.469

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

This Nursing Home:	0.160
State:	0.894

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	0.500
State:	1.350

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.090
State:	0.067

Number Therapy Hours Per Resident Per Day

Here:	0.090
Texas:	0.074

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	19.8%
Texas:	20.4%

Percent of long-stay residents who self-report moderate to severe pain

Here:	11.6%
State:	11.4%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	15.2%
Texas:	7.2%

Percent of long-stay residents who lose too much weight

This Nursing Home:	9.0%
State:	6.7%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Nursing Home:	60.0%
State:	46.0%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	3.4%
Texas:	3.9%

Percent of long-stay residents with a urinary tract infection

Here:	7.0%
State:	8.3%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	1.0%
State:	9.3%

Percent of long-stay residents who were physically restrained

Here:	11.9%
Texas:	1.6%

Percent of long-stay residents experiencing one or more falls with major injury

Here:	5.9%
State:	3.5%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	34.7%
Texas:	91.6%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	5.0%
State:	91.1%

Percent of short-stay residents who self-report moderate to severe pain

This Nursing Home:	20.5%
Texas:	20.2%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	64.5%
State:	76.2%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

Here:	4.1%
State:	74.3%

Percent of long-stay residents who received an antipsychotic medication

Here:	27.9%
Texas:	28.5%

Complaint Deficiency

A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Post nurse staffing information/data on a daily basis
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Restrictions on the use of flammable curtains
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper construction of ducts through walls designed to prevent smoke passage
- Harm: Potential for minimal harm
- Scope: Some
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Potential for minimal harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Back-up procedures in place for a faulty automatic sprinkler system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Restrictions on the use of highly flammable materials
- Harm: Potential for minimal harm
- Scope: Many
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide enough notice before discharging or transferring a resident
- Harm: Potential for minimal harm
- Scope: Many
Restrictions on the use of portable space heaters
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Restrictions on the use of portable space heaters
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Signs that state that exit doors are to be kept closed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow residents to easily view the results of the nursing home's most recent survey
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Immediately tell the resident, the resident's doctor and a family member of the resident of situations (injury/decline/room, etc.) that affect the resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Many
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly working sprinkler alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow residents to easily view the results of the nursing home's most recent survey
- Harm: Potential for minimal harm
- Scope: Many
Provide access to a telephone for resident to use in private
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide written records when a resident is transferred or discharged
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that residents are safe from serious medication errors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Some
1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator
- Harm: Potential for minimal harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly working sprinkler alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Potential for minimal harm
- Scope: Many
Weekly inspections and monthly testing of generators
- Harm: Potential for minimal harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Post nurse staffing information/data on a daily basis
- Harm: Potential for minimal harm
- Scope: Many
Make sure that special or therapeutic diets are ordered by the attending doctor
- Harm: Potential for minimal harm
- Scope: Some
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
1) Ensure lab services, blood blanks and transfusion services provided on site meet requirements for certified laboratories; or 2) Have an agreement to obtain services from an offsite laboratory, that meets the same requirements
- Harm: Potential for minimal harm
- Scope: Many
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure each resident receives an accurate assessment by a qualified health professional
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some

WINTERHAVEN HEALTHCARE CENTER - HOUSTON, TX

Staff Information

Quality Measures

Complaint Deficiency

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