VILLA HAVEN HEALTH AND REHABILITATION CENTER (BRECKENRIDGE, TX) Detailed Nursing Home Profile

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.360
State:	0.469

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

Here:	1.230
State:	0.894

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.590
Texas:	1.350

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.070
State:	0.067

Number Therapy Hours Per Resident Per Day

Here:	0.070
State:	0.074

Quality Measures

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

Here:	12.1%
State:	20.4%

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

This Nursing Home:	47.5%
State:	11.4%

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

Here:	12.1%
State:	7.2%

Percent of long-stay residents who lose too much weight

This Nursing Home:	12.5%
Texas:	6.7%

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

Here:	3.8%
State:	3.9%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	9.8%
Texas:	8.3%

Percent of long-stay residents who have depressive symptoms

Here:	5.7%
Texas:	9.3%

Percent of long-stay residents who were physically restrained

Here:	4.7%
State:	1.6%

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

This Nursing Home:	9.3%
State:	3.5%

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

This Nursing Home:	93.0%
Texas:	91.6%

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

This Nursing Home:	86.0%
Texas:	91.1%

Percent of long-stay residents who received an antipsychotic medication

Here:	32.6%
Texas:	28.5%

Complaint Deficiency

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
A fire alarm system that can be heard throughout the facility
- Harm: Potential for minimal harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Potential for minimal harm
- Scope: Some
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Potential for minimal harm
- Scope: Some
Fire-resistant room wall surfaces
- 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: Few
Signs that state that exit doors are to be kept closed
- 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: Many
Smoke barrier doors that can resist smoke for at least 20 minutes
- 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: Many
Exits that are accessible at all times
- 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: Many
Properly maintained smoke detectors
- Harm: Potential for minimal harm
- Scope: Some
Portable fire extinguishers
- Harm: Potential for minimal harm
- Scope: Some
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: Some
Properly installed electrical wiring and equipment
- 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: Potential for minimal 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
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Many
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly working alarms on sprinkler valves
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- 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: Some
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide activities to meet the interests and needs of each resident
- 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: 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 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: Some

VILLA HAVEN HEALTH AND REHABILITATION CENTER - BRECKENRIDGE, TX

Staff Information

Quality Measures

Complaint Deficiency

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