JULIETTE MANOR - BERLIN, WI

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
• A two-hour-resistant firewall in common walls
  • 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
• Signs that state that exit doors are to be kept closed
  • 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
• Keep accurate, complete and organized clinical records on each resident that meet professional standards
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Exits that are accessible at all times
  • Harm: Immediate jeopardy to resident health or safety
  • 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
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A two-hour-resistant firewall in common walls
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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: Many
• Corridor and hallway doors that block smoke
  • 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: Many
• Signs that state that exit doors are to be kept closed
  • 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
• Protected exits that allow the resident to escape the building
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Proper backup exit lighting
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Emergency lighting that can last at least 1 1/2 hours
  • 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: Some
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Proper medical gas storage and administration areas
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Weekly inspections and monthly testing of generators
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • 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: Few
• Provide care by qualified persons according to each resident's written plan of care
  • 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
• 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
• 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: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Make sure that paid feeding assistants 1) completed training; 2) works under the supervision of a RN or LPN; and 3) feeds only residents who have no complicated feeding problems
  • 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
• Have a program that investigates, controls and keeps infection from spreading
  • 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 maintained smoke detectors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Properly protected cooking facilities
  • 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
• A fire alarm system that can be heard throughout the facility
  • 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: Some
• Proper fire barriers, ventilation and signs for the transport of oxygen
  • 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
• Keep each resident's personal and medical records private and confidential
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide care by qualified persons according to each resident's written plan of care
  • 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: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 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: 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: Some
• Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some

Quality Measures