BROOKE GROVE REHAB. AND NSG CTR (SANDY SPRING, MD) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	16.0%
Maryland:	20.0%

Percent of long-stay residents who self-report moderate to severe pain

This Nursing Home:	5.0%
Maryland:	6.2%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	5.1%
Maryland:	7.7%

Percent of long-stay residents who lose too much weight

Here:	1.8%
State:	6.0%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

This Nursing Home:	0.9%
State:	3.1%

Percent of long-stay residents with a urinary tract infection

Here:	6.1%
State:	6.0%

Percent of long-stay residents who have depressive symptoms

Here:	9.0%
Maryland:	4.3%

Percent of long-stay residents experiencing one or more falls with major injury

This Nursing Home:	1.7%
State:	2.7%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	100.0%
State:	95.1%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	99.1%
Maryland:	95.2%

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

This Nursing Home:	33.3%
State:	16.5%

Percent of short-stay residents with Pressure ulcers that are new or worsened

Here:	2.7%
State:	1.3%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	94.7%
Maryland:	86.6%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	91.5%
Maryland:	85.7%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	1.0%
State:	2.8%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	12.3%
State:	19.2%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.560
State:	0.759

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.810
Maryland:	0.899

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.370
State:	1.649

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.140
Maryland:	0.108

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.140
State:	0.112

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
Hire sufficient dietary support personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- 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
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
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
- 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: Some
Hire sufficient dietary support personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Completely assess the resident at least every twelve months
- Harm: Potential for minimal harm
- Scope: Some
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: Potential for minimal harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Potential for minimal harm
- Scope: Some
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Post nurse staffing information/data on a daily basis
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
- Harm: Potential for minimal harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give the right treatment and services to residents who have mental or psychosocial problems adjusting
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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: Some
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
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that doctors visit residents regularly, as required
- Harm: Potential for minimal harm
- Scope: Some
Approved construction type or materials
- Harm: Potential for minimal harm
- Scope: Many
Fire-resistant room wall surfaces
- Harm: Potential for minimal harm
- Scope: Some
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Potential for minimal harm
- Scope: Some
Approved construction type or materials
- Harm: Potential for minimal harm
- Scope: Many
Fire-resistant room wall surfaces
- Harm: Potential for minimal harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Potential for minimal harm
- Scope: Many
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Potential for minimal harm
- Scope: Some
Emergency lighting that can last at least 1 1/2 hours
- Harm: Potential for minimal harm
- Scope: Many
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Potential for minimal harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Portable fire extinguishers
- Harm: Potential for minimal harm
- Scope: Some
Properly installed electrical wiring and equipment
- Harm: Potential for minimal harm
- Scope: Many
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- 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: Some
Provide necessary care and services to maintain the highest well being of each resident
- 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: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Potential for minimal harm
- Scope: Some
Approved construction type or materials
- Harm: Potential for minimal harm
- Scope: Many
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Potential for minimal harm
- Scope: Some
Exit stairways and towers that are smoke proof
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Emergency lighting that can last at least 1 1/2 hours
- Harm: Potential for minimal harm
- Scope: Some
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Potential for minimal harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Potential for minimal harm
- Scope: Many
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few

BROOKE GROVE REHAB. AND NSG CTR - SANDY SPRING, MD

Quality Measures

Staff Information

Complaint Deficiency

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