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

Quality Measures

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

Here:	18.2%
Texas:	20.4%

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

Here:	4.0%
State:	11.4%

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

Here:	12.8%
State:	7.2%

Percent of long-stay residents who lose too much weight

This Nursing Home:	12.7%
Texas:	6.7%

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

Here:	71.8%
Texas:	46.0%

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

Here:	3.9%
Texas:	3.9%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	8.5%
State:	8.3%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	15.2%
State:	9.3%

Percent of long-stay residents who were physically restrained

Here:	5.6%
Texas:	1.6%

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

Here:	1.4%
State:	3.5%

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

Here:	97.2%
State:	91.6%

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

Here:	95.8%
Texas:	91.1%

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

Here:	20.6%
Texas:	20.2%

Percent of short-stay residents with Pressure ulcers that are new or worsened

Here:	1.8%
State:	1.4%

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

This Nursing Home:	67.6%
State:	76.2%

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

This Nursing Home:	63.8%
Texas:	74.3%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	40.6%
State:	28.5%

Complaint Deficiency

Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A properly installed and maintained dumbwaiter or escalator
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide doctors orders for the resident's immediate care, at the time the resident was admitted
- 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
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper construction of ducts through walls designed to prevent smoke passage
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridors that are separated from common areas by walls constructed to limit the passage of smoke
- 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
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Did not have a written emergency evacuation plan
- Harm: Immediate jeopardy to resident health or safety
- 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
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A properly installed and maintained dumbwaiter or escalator
- 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
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- 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
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- 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: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- 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
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Many
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Potential for minimal harm
- Scope: Many
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Potential for minimal harm
- Scope: Many
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- 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: Some
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
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- 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: Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep complete, dated lab records in the resident's file
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Train all employees on what to do in an emergency, and carry out announced staff drills
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly located and lighted Exit signs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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 care by qualified persons according to each resident's written plan of care
- 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: Immediate jeopardy to resident health or safety
- Scope: Few
Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
- 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: Immediate jeopardy to resident health or safety
- Scope: Few
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 the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- 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: Some
Store, cook, and serve food in a safe and clean way
- 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
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Put firmly secured handrails on each side of hallways
- Harm: Minimal harm or potential for actual harm
- Scope: Some
1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compensation
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- 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: Many
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Many
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Many
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Potential for minimal harm
- Scope: Many
Have an adequate water supply for the sprinkler system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Potential for minimal harm
- Scope: Many
Properly protected cooking facilities
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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: Some
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
Provide bedrooms that don't allow residents to see each other when privacy is needed
- Harm: Potential for minimal harm
- Scope: Some
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
- Harm: Minimal harm or potential for actual harm
- Scope: Some

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.340
Texas:	0.469

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

Here:	1.160
State:	0.894

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.510
State:	1.350

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.150
State:	0.067

Number Therapy Hours Per Resident Per Day

Here:	0.150
State:	0.074

STONEYBROOK HEALTHCARE CENTER - HOUSTON, TX

Quality Measures

Complaint Deficiency

Staff Information

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