TALL PINES CARE AND REHAB, INC - SHOW LOW, AZ

Complaint Deficiency

• Automatic sprinkler systems that have been maintained in working order
  • 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: Some
• Provide doctors orders for the resident's immediate care, at the time the resident was admitted
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Fire-resistant room wall surfaces
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Signs that state that exit doors are to be kept closed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Review or revise the resident's care plan after any major change in a resident's physical or mental health
  • 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
• 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
• Restrictions on the use of portable space heaters
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Proper backup exit lighting
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide doctors orders for the resident's immediate care, at the time the resident was admitted
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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: Minimal harm or potential for actual harm
  • Scope: Few
• Provide housekeeping and maintenance services
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
• Give or get x-rays and other tests in a timely manner to meet the needs of residents
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Potential for minimal harm
  • Scope: Some
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Potential for minimal harm
  • Scope: Many
• Properly maintained smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 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 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: Some
• 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
• 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
• 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: Some
• 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: Some
• Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
  • Harm: Potential for minimal harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • 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: Potential for minimal harm
  • Scope: Many
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Potential for minimal harm
  • Scope: Some
• Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Doors of sufficient width and proper construction in smoke barriers
  • 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: Some
• Properly located and lighted Exit signs
  • 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: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly protected cooking facilities
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Exits that are free from obstructions and can be used 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: Some
• 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: 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: 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
• 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 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
• Corridor and hallway doors that block smoke
  • 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: Some
• Proper backup exit lighting
  • 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
• Properly maintained smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Automatic sprinkler systems that have been maintained in working order
  • 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: Some
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few

Quality Measures

Staff Information