DEANWOOD REHABILITATION AND WELLNESS CENTER - WASHINGTON, DC

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Staff Information

Quality Measures

Complaint Deficiency

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

Signs that state that exit doors are to be kept closed: 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)

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death: Few (Minimal harm or potential for actual harm)

Rooms that can be unlocked from inside without a key: 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)

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)

Approved construction type or materials: Few (Actual harm)

Exits that are accessible at all times: Many (Actual harm)

Allow the resident the right to participate in the planning or revision of the resident's care plan: Many (Actual harm)

Provide proof that all residents' personal money which is deposited with the nursing home, is secure: 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: Many (Actual harm)

Properly constructed piped-in oxygen systems: 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)

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

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death: Few (Minimal harm or potential for actual harm)

Make sure services provided by the nursing facility meet professional standards of quality: Some (Actual harm)

Provide proof that all residents' personal money which is deposited with the nursing home, is secure: Some (Actual harm)

Properly constructed piped-in oxygen systems: Some (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)

Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives: Few (Minimal harm or potential for actual harm)

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death: 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)

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

Corridors that are separated from common areas by walls constructed to limit the passage of smoke: Some (Minimal harm or potential for actual harm)

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

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

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

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

An approved installation, maintenance and testing program for fire alarm systems: Some (Minimal harm or potential for actual harm)

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

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

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death: Few (Minimal harm or potential for actual harm)

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

Try to resolve each resident's complaints quickly: Few (Minimal harm or potential for actual harm)

Provide access to a telephone for resident to use in private: 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: Few (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: Few (Minimal harm or potential for actual harm)

Check and assess each resident's assessment at least every 3 months: 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 : 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)

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)

Develop policies and procedures for influenza and pneumococcal immunizations: Few (Minimal harm or potential for actual harm)

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

Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing: Few (Minimal harm or potential for actual harm)

Give specialized rehabilitative services that are medically necessary by qualified personnel, when ordered by a doctor: Some (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 all essential equipment working safely: 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)

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: Some (Minimal harm or potential for actual harm)

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death: 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 medically-related social services to help each resident achieve the highest possible quality of life: Few (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: Some (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 necessary care and services to maintain the highest well being of each resident : Few (Minimal harm or potential for actual harm)

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)

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)

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)

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

Keep all essential equipment working safely: Some (Minimal harm or potential for actual harm)

Make sure that a working call system is available in each resident's room or bathroom and bathing area: Few (Minimal harm or potential for actual harm)

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

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

1) Set up a group that is legally responsible for writing and setting up policies for leading and running the nursing home; or 2) hire a properly licensed administrator: 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)

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)

Corridors that are separated from common areas by walls constructed to limit the passage of smoke: Some (Minimal harm or potential for actual harm)

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

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

A properly located automatic smoke detector system in all hallways: 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)

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: 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)

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

Provide access to a telephone for resident to use in private: Few (Minimal harm or potential for actual harm)

Notify the resident or provide reasons for a transfer or discharge: 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 care for residents in a way that keeps or builds each resident's dignity and respect of individuality: Few (Minimal harm or potential for actual harm)

Give notice to the resident before a room or roommate change: Few (Minimal harm or potential for actual harm)

Provide housekeeping and maintenance services: Some (Minimal harm or potential for actual harm)

Maintain comfortable and safe temperature levels: 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: 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: Some (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: Some (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 : Some (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)

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: 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)

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

Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing: Few (Minimal harm or potential for actual 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)

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: Many (Minimal harm or potential for actual harm)

Keep all essential equipment working safely: Many (Minimal harm or potential for actual harm)

Make sure that a working call system is available in each resident's room or bathroom and bathing area: 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)

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)

Corridors that are separated from common areas by walls constructed to limit the passage of smoke: Some (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Some (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)

An approved installation, maintenance and testing program for fire alarm systems: Some (Minimal harm or potential for actual harm)

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