TIVOLI AT DIVINE SAVIOR HEALTHCARE - PORTAGE, WI

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Quality Measures

Staff Information

Complaint Deficiency

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

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

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

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)

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Few (Minimal harm or potential for actual harm)

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

Exits that are accessible at all times: Few (Immediate jeopardy to resident health or safety)

Resident room doors of proper design and width: Few (Minimal harm or potential for actual harm)

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

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Some (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Some (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)

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

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Few (Minimal harm or potential for actual harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: 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)

Back-up procedures in place for a faulty automatic sprinkler system: Few (Minimal harm or potential for actual harm)

Properly working alarms on sprinkler valves: Few (Minimal harm or potential for actual harm)

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

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

Other fire safety features required by fire safety codes: Some (Minimal harm or potential for actual harm)

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

Properly working alarms on sprinkler valves: Few (Minimal harm or potential for actual harm)

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

Heating and ventilation systems that have been properly installed according to the manufacturer's instructions: Many (Minimal harm or potential for actual harm)

Exits that are free from obstructions and can be used at all times: Few (Minimal harm or potential for actual harm)

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

Fire-resistant interior walls: Many (Minimal harm or potential for actual harm)

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

Corridors that are separated from common areas by walls constructed to limit the passage of smoke: Many (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)

Exit stairways and towers that are smoke proof: Some (Minimal harm or potential for actual harm)

Did not have a written emergency evacuation plan: Many (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Many (Potential for minimal harm)

A fire alarm system that can be heard throughout the facility: Many (Minimal harm or potential for actual harm)

An automatic smoke detection system in all hallways: Many (Minimal harm or potential for actual harm)

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

Properly constructed linen or trash chutes: Some (Minimal harm or potential for actual harm)

Exits that are free from obstructions and can be used at all times: Some (Minimal harm or potential for actual harm)

Restrictions on the use of flammable curtains: Many (Minimal harm or potential for actual harm)

Properly installed hallway dispensers for alcohol-based hand rub: 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)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: 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)

Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%: Few (Minimal harm or potential for actual harm)

Make sure that all needed doctor visits are made personally by a doctor, as required. After initial doctor visit, care may be alternated by a physician assistant (PA) or nurse practitioner (NP): Few (Minimal harm or potential for actual harm)

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

Smoke barrier doors that can resist smoke for at least 20 minutes: 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)

Properly located and lighted Exit signs: Few (Minimal harm or potential for actual harm)

Properly maintained smoke detectors: Few (Minimal harm or potential for actual harm)

Exits that are free from obstructions and can be used at all times: Some (Minimal harm or potential for actual harm)

Properly sized and located linen or trash receptacles: Few (Minimal harm or potential for actual harm)

Proper fire barriers, ventilation and signs for the transport of oxygen: Few (Minimal harm or potential for actual harm)

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

Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for: Many (Potential for minimal 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)

Reasonably accommodate the needs and preferences of each resident: Few (Minimal harm or potential for actual harm)

Provide activities to meet the interests and needs of each resident: Some (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)

Provide care by qualified persons according to each resident's written plan of care: 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 (Minimal harm or potential for actual harm)

Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion: 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: Some (Minimal harm or potential for actual harm)

Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so: Few (Immediate jeopardy to resident health or safety)

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)

Post nurse staffing information/data on a daily basis: Many (Potential for minimal harm)

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: Many (Potential for minimal harm)

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

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

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

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

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

Properly sized and located linen or trash receptacles: Few (Minimal harm or potential for actual harm)

Weekly inspections and monthly testing of generators: Many (Minimal harm or potential for actual harm)

Back-up procedures in place for a faulty automatic sprinkler system: Many (Minimal harm or potential for actual harm)

An approved back-up procedure for a faulty fire alarm system: Many (Minimal harm or potential for actual harm)

Review or revise the resident's care plan after any major change in a resident's physical or mental health: Few (Minimal harm or potential for actual harm)

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

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Some (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)

Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so: Few (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)

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)

Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature: Few (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Many (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)

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