MARIANJOY REHABILITATION HOSPITAL-SNF - WHEATON, IL

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Staff Information

Quality Measures

Complaint Deficiency

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

Corridor and hallway doors that block smoke: 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: Some (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)

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

Properly installed hallway dispensers for alcohol-based hand rub: Many (Minimal harm or potential for actual harm)

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

Proper stairway enclosures and vertical shafts: 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)

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

Properly maintained smoke detectors: Many (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)

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 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)

Listen to the resident or family groups or act on their complaints or suggestions: Few (Minimal harm or potential for actual harm)

Conduct initial and periodic assessments of each resident's functional capacity: 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)

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

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: Many (Minimal harm or potential for actual harm)

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

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

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

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