CRESTVIEW HEALTH AND REHABILITATION - NASHVILLE, TN

Staff Information

Complaint Deficiency

• Restrictions on the use of portable space heaters
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: Few
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Minimal harm or potential for actual harm
  • 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: Few
• Proper construction of ducts through walls designed to prevent smoke passage
  • 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: Few
• Properly installed electrical wiring and equipment
  • 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
• 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 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
• Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that residents are safe from serious medication errors
  • 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: Minimal harm or potential for actual harm
  • Scope: Few
• 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
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: Few
• Properly installed electrical wiring and equipment
  • 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: Few
• Allow the resident the right to participate in the planning or revision of the resident's care plan
  • 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: 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
• 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
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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
• Make sure that residents are safe from serious medication errors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Proper stairway enclosures and vertical shafts
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: Few
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: Few
• Properly installed electrical wiring and equipment
  • 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
• 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
  • Harm: Actual harm
  • Scope: Few
• Send and promptly deliver unopened mail to residents
  • Harm: Potential for minimal harm
  • Scope: Many
• Protect each resident from all abuse, physical punishment, and being separated from others
  • Harm: Actual harm
  • Scope: Few
• Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
  • Harm: Actual harm
  • Scope: Few
• 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
  • Harm: Actual harm
  • Scope: Few
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Actual harm
  • Scope: Few
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Immediate jeopardy to resident health or safety
  • 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: Few
• Provide medically-related social services to help each resident achieve the highest possible quality of life
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide housekeeping and maintenance services
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: 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
• Allow the resident the right to participate in the planning or revision of the resident's care plan
  • Harm: Actual harm
  • Scope: Few
• Provide care by qualified persons according to each resident's written plan of care
  • Harm: Actual harm
  • Scope: Few
• Provide necessary care and services to maintain the highest well being of each resident
  • Harm: 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: Few
• Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
  • Harm: Immediate jeopardy to resident health or safety
  • 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
• Give the right treatment and services to residents who have mental or psychosocial problems adjusting
  • Harm: Actual harm
  • Scope: Few
• Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
  • Harm: Actual harm
  • Scope: Few
• Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
  • Harm: Immediate jeopardy to resident health or safety
  • 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: Actual harm
  • Scope: Few
• Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that residents are safe from serious medication errors
  • 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
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide or obtain dental services for each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: Few
• Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
  • 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
• Keep all essential equipment working safely
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that a working call system is available in each resident's room or bathroom and bathing area
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Be administered in an acceptable way that maintains the well-being of each resident
  • Harm: Actual harm
  • Scope: Few
• Keep clinical record information safe, so that it will not be lost, destroyed or used by the wrong person
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
  • Harm: Actual harm
  • Scope: Few

Quality Measures