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EAST OHIO REGIONAL HOSPITAL - MARTINS FERRY, OH

 



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Address
90 NORTH FOURTH STREET
MARTINS FERRY, OH, 43935
Phone (make sure to verify first before calling): (740) 633-4262

Number of Certified Beds: 50
Total Number of Residents: 48
Percent of Occupied Beds: 96%
Sprinkler Status: Fully Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: Non profit - Corporation
Located Within a Hospital?: Yes
Multi Nursing Home Ownership?: No
Resident and Family Councils: Both
Continuing Care Retirement Community?: No
Quality Indicator Survey?: No
Special Focus Facility?: No
Type: Skilled Nursing Facilities

Overall Star Rating: 1 Star
Health Inspections Star Rating: 1 Star
Nurse Staffing Star Rating: 3 Stars
Quality Measures Star Rating: 1 Star
RN Only Star Rating: 4 Stars

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Acute Myocardial Infarction, Discharged Alive with Major Complications
Average Covered Charges
Here:

$19,524
State:

$39,579
Average Total Payments
This Nursing Home:

$8,751
State:

$11,622
Number of discharges: 13
This Nursing Home:

1.93%
State:

0.87%
Cardiac Arrhythmia and Conduction Disorders with Complications
Average Covered Charges
This Nursing Home:

$14,316
State:

$17,343
Average Total Payments
This Nursing Home:

$4,512
Ohio:

$5,360
Number of discharges: 16
This Nursing Home:

2.37%
State:

1.61%
Cardiac Arrhythmia and Conduction Disorders without Complications
Average Covered Charges
Here:

$10,047
State:

$12,756
Average Total Payments
Here:

$3,135
State:

$3,704
Number of discharges: 19
This Nursing Home:

2.81%
Ohio:

1.70%
Cellulitis without Major Complications
Average Covered Charges
Here:

$13,667
Ohio:

$14,248
Average Total Payments
Here:

$4,527
Ohio:

$5,264
Number of discharges: 55
This Nursing Home:

8.15%
State:

2.07%
Chronic Obstructive Pulmonary Disease with Complications
Average Covered Charges
This Nursing Home:

$13,323
Ohio:

$18,588
Average Total Payments
This Nursing Home:

$5,381
State:

$6,116
Number of discharges: 57
Here:

8.44%
State:

2.58%
Chronic Obstructive Pulmonary Disease with Major Complications
Average Covered Charges
Here:

$17,899
State:

$23,243
Average Total Payments
Here:

$6,440
State:

$7,305
Number of discharges: 33
This Nursing Home:

4.89%
State:

2.57%
Chronic Obstructive Pulmonary Disease without Complications
Average Covered Charges
Here:

$10,461
State:

$13,703
Average Total Payments
This Nursing Home:

$3,961
Ohio:

$4,558
Number of discharges: 31
This Nursing Home:

4.59%
Ohio:

1.95%
Circulatory Disorders Except Acute Myocardial Infarction, with Card Cath without Major Complications
Average Covered Charges
Here:

$26,209
State:

$29,294
Average Total Payments
Here:

$5,978
State:

$7,304
Number of discharges: 13
This Nursing Home:

1.93%
State:

1.71%
Diabetes with Complications
Average Covered Charges
Here:

$14,091
State:

$17,034
Average Total Payments
This Nursing Home:

$4,562
Ohio:

$5,364
Number of discharges: 11
This Nursing Home:

1.63%
Ohio:

0.68%
Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications
Average Covered Charges
This Nursing Home:

$14,775
Ohio:

$15,976
Average Total Payments
This Nursing Home:

$3,942
State:

$4,676
Number of discharges: 24
This Nursing Home:

3.56%
Ohio:

3.54%
G.I. Hemorrhage with Complications
Average Covered Charges
Here:

$18,425
Ohio:

$21,460
Average Total Payments
This Nursing Home:

$5,592
Ohio:

$6,445
Number of discharges: 15
Here:

2.22%
Ohio:

1.96%
Heart Failure and Shock with Complications
Average Covered Charges
This Nursing Home:

$14,853
Ohio:

$20,118
Average Total Payments
This Nursing Home:

$5,559
State:

$6,456
Number of discharges: 42
This Nursing Home:

6.22%
State:

3.25%
Heart Failure and Shock with Major Complications
Average Covered Charges
Here:

$30,389
State:

$30,968
Average Total Payments
This Nursing Home:

$8,191
State:

$9,501
Number of discharges: 25
Here:

3.70%
Ohio:

2.81%
Heart Failure and Shock without Complications
Average Covered Charges
Here:

$10,476
Ohio:

$13,715
Average Total Payments
This Nursing Home:

$3,765
State:

$4,264
Number of discharges: 28
This Nursing Home:

4.15%
Ohio:

1.27%
Kidney and Urinary Tract Infections with Major Complications
Average Covered Charges
Here:

$20,568
State:

$22,043
Average Total Payments
This Nursing Home:

$6,482
State:

$7,392
Number of discharges: 11
Here:

1.63%
Ohio:

1.00%
Kidney and Urinary Tract Infections without Major Complications
Average Covered Charges
This Nursing Home:

$12,857
State:

$14,573
Average Total Payments
This Nursing Home:

$4,277
Ohio:

$4,878
Number of discharges: 24
Here:

3.56%
Ohio:

2.95%
Major Joint Replacement or Reattachment of Lower Extremity without Major Complications
Average Covered Charges
Here:

$30,639
State:

$43,077
Average Total Payments
Here:

$10,850
State:

$13,260
Number of discharges: 74
Here:

10.96%
Ohio:

5.47%
Misc Disorders of Nutrition, Metabolism, Fluids or Electrolytes without Major Complications
Average Covered Charges
Here:

$11,213
Ohio:

$13,909
Average Total Payments
This Nursing Home:

$3,675
State:

$4,364
Number of discharges: 19
This Nursing Home:

2.81%
State:

2.09%
Other Vascular Procedures with Complications
Average Covered Charges
This Nursing Home:

$42,582
State:

$57,956
Average Total Payments
Here:

$13,189
Ohio:

$16,269
Number of discharges: 15
This Nursing Home:

2.22%
Ohio:

0.59%
Permanent Cardiac Pacemaker Implant without Complications
Average Covered Charges
Here:

$26,866
Ohio:

$45,808
Average Total Payments
This Nursing Home:

$11,124
Ohio:

$12,918
Number of discharges: 12
This Nursing Home:

1.78%
Ohio:

0.36%
Red Blood Cell Disorders without Major Complications
Average Covered Charges
Here:

$9,605
Ohio:

$17,326
Average Total Payments
Here:

$4,371
State:

$5,281
Number of discharges: 11
This Nursing Home:

1.63%
State:

1.29%
Renal Failure with Complications
Average Covered Charges
This Nursing Home:

$21,539
State:

$20,095
Average Total Payments
Here:

$5,627
State:

$6,487
Number of discharges: 12
This Nursing Home:

1.78%
Ohio:

2.36%
Respiratory System Diagnosis with Ventilator Support <96 Hours
Average Covered Charges
This Nursing Home:

$48,554
Ohio:

$49,977
Average Total Payments
Here:

$12,594
Ohio:

$14,939
Number of discharges: 11
Here:

1.63%
State:

1.18%
Septicemia or Severe Sepsis without Mechanical Ventilation 96+ Hours with Major Complications
Average Covered Charges
This Nursing Home:

$29,988
Ohio:

$39,192
Average Total Payments
This Nursing Home:

$10,161
State:

$12,220
Number of discharges: 11
Here:

1.63%
Ohio:

3.71%
Simple Pneumonia and Pleurisy with Complications
Average Covered Charges
Here:

$16,265
State:

$18,745
Average Total Payments
This Nursing Home:

$5,367
State:

$6,275
Number of discharges: 38
This Nursing Home:

5.63%
Ohio:

2.85%
Simple Pneumonia and Pleurisy with Major Complications
Average Covered Charges
Here:

$21,921
Ohio:

$29,030
Average Total Payments
This Nursing Home:

$7,993
State:

$9,075
Number of discharges: 18
This Nursing Home:

2.67%
State:

2.14%
Simple Pneumonia and Pleurisy without Complications
Average Covered Charges
This Nursing Home:

$11,359
State:

$13,590
Average Total Payments
This Nursing Home:

$3,897
Ohio:

$4,407
Number of discharges: 14
This Nursing Home:

2.07%
State:

1.11%
Syncope and Collapse
Average Covered Charges
Here:

$16,407
Ohio:

$16,283
Average Total Payments
Here:

$3,940
State:

$4,578
Number of discharges: 23
Here:

3.41%
State:

2.11%

Employment Full-Time Equivalent

Administrative Staff - Full Time: 2.86
Certified Nurse Aides - Full Time: 24.43
Certified Nurse Aides - Part Time: 7.49
Food Service Personnel - Full Time: 5.80
Food Service Personnel - Part Time: 2.40
Housekeeping Personnel - Full Time: 1.60
Licensed Practical/ Vocational Nurses - Full Time: 12.74
Licensed Practical/ Vocational Nurses - Part Time: 4.40
Nurses With Administrative Duties - Full Time: 4.57
Persons Not Included In Any Other Categories - Full Time: 2.06
Registered Nurses - Full Time: 8.51
Rn Director Of Nursing - Full Time: 1.14
Social Workers - Full Time: 1.14
Activities Professionals - Full Time: 1.14
Medical Directors - Part Time: 0.57
Dietitians - Full Time: 1.14
Sppech Pathologists - Full Time: 0.57
Persons Not Included In Any Other Categories - Part Time: 0.57
Registered Nurses - Part Time: 7.94
Occupational Therapists - Full Time: 1.14
Physical Therapists - Full Time: 1.14
Occupational Therapy Assistants - Full Time: 1.14
Physical Therapy Aide - Full Time: 1.14
Pharmacists - Part Time: 0.57

Provided Services

  • Activities Services Are Provided Onsite To Residents
  • Administration And Storage Of Blood Services Are Provided Onsite To Residents
  • Clinical Laboratory Services Are Provided Onsite To Residents
  • Dental Services Are Provided Onsite To Residents
  • Diagnostic Xray Services Are Provided Onsite To Residents
  • Dietary Services Are Provided Onsite To Residents
  • Housekeeping Services Are Provided Onsite To Residents
  • Mental Health Services Are Provided Onsite To Residents
  • Nursing Services Are Provided Onsite To Residents
  • Occupational Therapy Services Are Provided Onsite To Residents
  • Pharmacy Services Are Provided Onsite To Residents
  • Physical Therapy Services Are Provided Onsite To Residents
  • Physician Services Are Provided Onsite To Residents
  • Podiatry Services Are Provided Onsite To Residents
  • Social Work Services Are Provided Onsite To Residents
  • Speech/Language Pathology Services Are Provided Onsite To Residents

Staff Information

Number of Registered Nurses Hours Per Resident Per Day
This Nursing Home:

1.210
Ohio:

0.670
Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day
This Nursing Home:

0.660
State:

0.885
Total Number of Licensed Staff Hours Per Resident Per Day
Here:

1.870
Ohio:

1.552
Number of ,Certified Nurse Assistant Hours Per Resident Per Day
Here:

0.060
State:

0.066
Number Therapy Hours Per Resident Per Day
This Nursing Home:

0.060
Ohio:

0.069

Use of Medical Imaging

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.
This Nursing Home:

15.500%
State:

8.691%
Outpatient CT scans of the abdomen that were combination (double) scans.
Here:

0.580%
State:

0.119%
Outpatient CT scans of the chest that were combination (double) scans.
This Nursing Home:

0.011%
Ohio:

0.024%
Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery
Here:

4.900%
State:

5.607%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys: 300 or more
Survey Response Rate: 28%

How often did nurses communicate well with patients?

Sometimes or never
This Nursing Home:

8%
Ohio:

4%
Usually
Here:

23%
Ohio:

17%
Always
Here:

69%
Ohio:

79%

How often did doctors communicate well with patients?

Sometimes or never
This Nursing Home:

8%
Ohio:

5%
Usually
This Nursing Home:

21%
Ohio:

16%
Always
This Nursing Home:

71%
State:

79%

How often did patients receive help quickly from hospital staff?

Sometimes or never
This Nursing Home:

14%
State:

8%
Usually
Here:

30%
Ohio:

25%
Always
This Nursing Home:

56%
State:

67%

How often was patients' pain well controlled?

Sometimes or never
Here:

10%
State:

6%
Usually
This Nursing Home:

26%
Ohio:

24%
Always
Here:

64%
Ohio:

70%

How often did staff explain about medicines before giving them to patients?

Sometimes or never
Here:

26%
Ohio:

20%
Usually
Here:

17%
State:

18%
Always
Here:

57%
Ohio:

62%

How often were the patients' rooms and bathrooms kept clean?

Sometimes or never
Here:

10%
State:

7%
Usually
This Nursing Home:

24%
State:

19%
Always
This Nursing Home:

66%
Ohio:

74%

How often was the area around patients' rooms kept quiet at night?

Sometimes or never
Here:

17%
Ohio:

11%
Usually
Here:

35%
Ohio:

32%
Always
Here:

48%
Ohio:

57%

Were patients given information about what to do during their recovery at home?

Yes
This Nursing Home:

76%
State:

85%
No
Here:

24%
State:

15%

How do patients rate the hospital overall on a scale from 0 (lowest) to 10 (highest)?

6 or lower
Here:

17%
State:

8%
7 or 8
Here:

28%
State:

22%
9 or 10
Here:

55%
State:

70%

Would patients recommend the hospital to friends and family?

No
This Nursing Home:

10%
Ohio:

4%
Yes, probably
Here:

34%
State:

25%
Yes, definitely
This Nursing Home:

56%
Ohio:

71%

Quality Measures

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

39.1%
State:

26.0%
Percent of short-stay residents with Pressure ulcers that are new or worsened
Here:

2.7%
Ohio:

1.6%
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
Here:

94.3%
State:

86.0%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine
This Nursing Home:

92.0%
State:

84.9%

Process of Care

Heart Attack

Percent of Patients Given Aspirin at Arrival
This Nursing Home:

94.0%
State:

99.4%
Percent of Patients Given Aspirin at Discharge
Here:

97.0%
Ohio:

99.1%
Percent of Patients Given Beta Blocker at Discharge
Here:

100.0%
Ohio:

99.3%
Average number of minutes before outpatients with chest pain or possible heart attack got an ECG
Here:

7
Ohio:

7
Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival
This Nursing Home:

96.0%
State:

96.0%
Patients Given a Prescription for a Statin at Discharge
This Nursing Home:

62.0%
Ohio:

97.8%

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)
Here:

99.0%
State:

99.5%
Percent of Patients Given ACE Inhibitor or ARB for Left Ventricular Systolic Dysfunction (LVSD)
Here:

93.0%
Ohio:

96.8%
Percent of Patients Given Discharge Instructions
Here:

94.0%
Ohio:

94.0%
Percent of Patients Given Smoking Cessation Advice/Counseling
This Nursing Home:

100.0%
Ohio:

99.4%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival
Here:

95.0%
State:

96.3%
Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics
This Nursing Home:

97.0%
Ohio:

97.6%
Percent of Patients Given Smoking Cessation Advice/Counseling
Here:

100.0%
Ohio:

98.8%
Percent of Patients Given the Most Appropriate Initial Antibiotic(s)
Here:

89.0%
State:

95.6%
Percent of Patients Assessed and Given Influenza Vaccination
Here:

98.0%
Ohio:

94.8%
Percent of Patients Assessed and Given Pneumococcal Vaccination
Here:

92.0%
Ohio:

96.7%

Surgery

Percent of Surgery Patients given an antibiotic at the right time (within one hour before surgery) to help prevent infection
This Nursing Home:

97.0%
State:

98.2%
Percent of Surgery Patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)
Here:

88.0%
State:

97.2%
Percent of Surgery Patients who were given the right kind of antibiotic to help prevent infection
Here:

100.0%
Ohio:

98.8%
Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot
This Nursing Home:

94.0%
Ohio:

97.1%
Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries
This Nursing Home:

94.0%
State:

98.2%
Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method
This Nursing Home:

100.0%
Ohio:

99.9%
Percent of Surgery Patients whose urinary catheters were removed on the first or second day after surgery
Here:

95.0%
Ohio:

94.6%
Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on them
Here:

99.0%
State:

97.1%
Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)
Here:

75.0%
Ohio:

95.7%
Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)
This Nursing Home:

95.0%
Ohio:

96.3%
Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal
Here:

99.0%
State:

99.7%

Outcome of Care

30-Day Mortality Rates from Heart Attack
Here:

18.0%
Ohio:

15.3%
30-Day Mortality Rates from Heart Failure
Here:

13.7%
State:

11.2%
30-Day Mortality Rates from Pneumonia
This Nursing Home:

13.5%
State:

11.6%
30-Day Readmission Rates from Heart Failure
Here:

25.5%
Ohio:

25.0%
30-Day Readmission Rates from Pneumonia
This Nursing Home:

20.5%
State:

19.0%

Hospital Acquired Conditions

Falls and injuries
Here:

0.390%
State:

0.740%
Infection from a Urinary Catheter
This Nursing Home:

0.390%
Ohio:

0.391%

Complaint Deficiency

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)

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

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

Approved construction type or materials: Some (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: 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)

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

An approved installation, maintenance and testing program for fire alarm systems: Few (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)

Restrictions on the use of highly flammable materials: Some (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: 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 activities to meet the interests and needs of each resident: Some (Minimal harm or potential for actual harm)

Provide a safe, clean, comfortable and homelike environment: Some (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: 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)

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)

Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene: 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 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 the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents: Few (Immediate jeopardy to resident health or safety)

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

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

Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist: 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)

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)

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: Some (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)

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

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

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor: 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: Some (Minimal harm or potential for actual harm)

Train all employees on what to do in an emergency, and carry out announced staff drills: Many (Minimal harm or potential for actual harm)

Approved construction type or materials: Few (Minimal harm or potential for actual harm)

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

Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors: Some (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)

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

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

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

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

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

Approved construction type or materials: Many (Minimal harm or potential for actual harm)

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

Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors: Many (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: Many (Minimal harm or potential for actual harm)

An approved installation, maintenance and testing program for fire alarm systems: 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)

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

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

Weekly inspections and monthly testing of generators: Many (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)

Protect each resident from all abuse, physical punishment, and being separated from others: 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: 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 activities to meet the interests and needs of each resident: Few (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: 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)

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)

Provide care by qualified persons according to each resident's written plan of care: 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: 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)

At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor: Few (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Many (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)

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