FALLBROOK NURSING AND REHABILITATION - HOUSTON, TX

Staff Information

Quality Measures

Complaint Deficiency

• Make sure services provided by the nursing facility meet professional standards of quality
  • 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
• Try to resolve each resident's complaints quickly
  • 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: Few
• Approved construction type or materials
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Automatic sprinkler systems that have been maintained in working order
  • 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
• Post nurse staffing information/data on a daily basis
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Exits that are accessible at all times
  • Harm: Immediate jeopardy to resident health or safety
  • 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
• 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
• Exits that are free from obstructions and can be used at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Signs that state that exit doors are to be kept closed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: 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
• Proper backup exit lighting
  • 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: 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: Actual harm
  • Scope: Some
• Proper medical gas storage and administration areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Restrictions on the use of portable space heaters
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Post nurse staffing information/data on a daily basis
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
  • 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
• Exits that are free from obstructions and can be used at all times
  • 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: Few
• Properly located and lighted Exit signs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have a program that investigates, controls and keeps infection from spreading
  • 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: Potential for minimal harm
  • Scope: Many
• An approved automatic sprinkler system connected to the fire alarm system
  • 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
• Properly protected cooking facilities
  • Harm: Potential for minimal harm
  • Scope: Many
• Weekly inspections and monthly testing of generators
  • Harm: Potential for minimal harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • Harm: Potential for minimal harm
  • Scope: Many
• Provide proof that all residents' personal money which is deposited with the nursing home, is secure
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Keep each resident's personal and medical records private and confidential
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
  • 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: 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
• Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
  • 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: Immediate jeopardy to resident health or safety
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • 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: Some
• An approved installation, maintenance and testing program for fire alarm systems
  • 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
• Restrictions on the use of flammable curtains
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 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: Few
• Provide activities to meet the interests and needs of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure each resident receives an accurate assessment by a qualified health professional
  • 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: 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
• 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: Some
• Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
  • 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: Few
• Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
• 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
• Give or get x-rays and other tests in a timely manner to meet the needs of residents
  • 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