NORTH MOUNTAIN MEDICAL AND REHABILITATION CENTER - PHOENIX, AZ

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Staff Information

Quality Measures

Complaint Deficiency

An approved automatic sprinkler system connected to the fire alarm system: Few (Minimal harm or potential for actual harm)

Approved construction type or materials: Some (Immediate jeopardy to resident health or safety)

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: Few (Minimal harm or potential for actual harm)

A two-hour-resistant firewall in common walls: Few (Minimal harm or potential for actual harm)

Proper medical gas storage and administration areas: Some (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Immediate jeopardy to resident health or safety)

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death: Few (Immediate jeopardy to resident health or safety)

1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day: Few (Minimal harm or potential for actual harm)

Proper backup exit lighting: Few (Immediate jeopardy to resident health or safety)

Conduct initial and periodic assessments of each resident's functional capacity: Few (Immediate jeopardy to resident health or safety)

An approved back-up procedure for a faulty fire alarm system: Few (Immediate jeopardy to resident health or safety)

Exits that are accessible at all times: Some (Minimal harm or potential for actual harm)

Hire sufficient dietary support personnel: Few (Minimal harm or potential for actual harm)

Provide doctors orders for the resident's immediate care, at the time the resident was admitted: Few (Minimal harm or potential for actual harm)

1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents: Some (Minimal harm or potential for actual harm)

Provide proof that all residents' personal money which is deposited with the nursing home, is secure: Some (Minimal harm or potential for actual harm)

Properly hold, secure and manage each resident's personal money which is deposited with the nursing home: Some (Minimal harm or potential for actual harm)

Fire-resistant room wall surfaces: Many (Minimal harm or potential for actual harm)

Signs that state that exit doors are to be kept closed: Few (Minimal harm or potential for actual harm)

Signs that state that exit doors are to be kept closed: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Few (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Corridors or aisles that are unobstructed and are at least 8 feet in width: Some (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

Keep each resident's personal and medical records private and confidential: Some (Minimal harm or potential for actual harm)

Keep each resident free from physical restraints, unless needed for medical treatment: Few (Minimal harm or potential for actual harm)

Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property: Some (Immediate jeopardy to resident health or safety)

1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents: Few (Minimal harm or potential for actual harm)

Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property: Few (Minimal harm or potential for actual harm)

Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality: Some (Minimal harm or potential for actual harm)

Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care: Few (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Few (Immediate jeopardy to resident health or safety)

Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves: Few (Minimal harm or potential for actual harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Few (Immediate jeopardy to resident health or safety)

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: Few (Immediate jeopardy to resident health or safety)

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: Few (Immediate jeopardy to resident health or safety)

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Some (Minimal harm or potential for actual harm)

Give each resident enough fluids to keep them healthy and prevent dehydration: Few (Minimal harm or potential for actual harm)

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses: Few (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Make sure that residents are safe from serious medication errors: Few (Minimal harm or potential for actual harm)

Have enough nurses to care for every resident in a way that maximizes the resident's well being: Some (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Some (Potential for minimal harm)

Be administered in an acceptable way that maintains the well-being of each resident : Some (Minimal harm or potential for actual harm)

Give or get quality lab services/tests in a timely manner to meet the needs of residents: Few (Minimal harm or potential for actual harm)

Quickly tell the resident's doctor the results of lab tests: Few (Minimal harm or potential for actual harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Some (Minimal harm or potential for actual harm)

Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action: Many (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Some (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Some (Minimal harm or potential for actual harm)

Proper backup exit lighting: Few (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Few (Minimal harm or potential for actual harm)

Properly maintained smoke detectors: Many (Potential for minimal harm)

Automatic sprinkler systems that have been maintained in working order: Some (Minimal harm or potential for actual harm)

Portable fire extinguishers: Some (Potential for minimal harm)

Proper medical gas storage and administration areas: Some (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Some (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Keep each resident free from physical restraints, unless needed for medical treatment: Few (Minimal harm or potential for actual harm)

Conduct initial and periodic assessments of each resident's functional capacity: Few (Minimal harm or potential for actual harm)

Make sure each resident receives an accurate assessment by a qualified health professional: Few (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Allow the resident the right to participate in the planning or revision of the resident's care plan: Few (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Few (Minimal harm or potential for actual harm)

Provide necessary care and services to maintain the highest well being of each resident : Few (Minimal harm or potential for actual harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Few (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Few (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Some (Minimal harm or potential for actual harm)

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests: Some (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Few (Minimal harm or potential for actual harm)

Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses: Few (Minimal harm or potential for actual harm)

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards: Few (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Few (Minimal harm or potential for actual harm)