BOURBONNAIS TERRACE NURSING HOME - BOURBONNAIS, IL

Quality Measures

Complaint Deficiency

• 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
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure services provided by the nursing facility meet professional standards of quality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Corridors that are separated from common areas by walls constructed to limit the passage of smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Corridor and hallway doors that block smoke
  • 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: Minimal harm or potential for actual harm
  • Scope: Many
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • 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: Some
• Provide housekeeping and maintenance services
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give or get specialized rehabilitative services per the patient's assessment or plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have enough outside ventilation via a window or mechanical ventilation, or both
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• An approved automatic sprinkler system connected to the fire alarm system
  • 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
• Portable fire extinguishers
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide a safe, clean, comfortable and homelike environment
  • 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: Few
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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 the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Develop policies and procedures for influenza and pneumococcal immunizations
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Give or get specialized rehabilitative services per the patient's assessment or plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure there is a pest control program to prevent/deal with mice, insects, or other pests
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
  • 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: Minimal harm or potential for actual harm
  • Scope: Many
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Did not have a written emergency evacuation plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Potential for minimal harm
  • Scope: Many
• Properly maintained smoke detectors
  • 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
• Back-up procedures in place for a faulty automatic sprinkler system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• An approved back-up procedure for a faulty fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many

Staff Information