MILLBROOK HEALTHCARE AND REHABILITATION CENTER - LANCASTER, TX

Staff Information

Quality Measures

Complaint Deficiency

• Approved construction type or materials
  • Harm: Immediate jeopardy to resident health or safety
  • 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: Minimal harm or potential for actual harm
  • Scope: Some
• A two-hour-resistant firewall in common walls
  • 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: Immediate jeopardy to resident health or safety
  • Scope: Some
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
  • 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
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Potential for minimal harm
  • Scope: Many
• Automatic sprinkler systems that have been maintained in working order
  • Harm: Potential for minimal harm
  • Scope: Many
• Properly protected cooking facilities
  • Harm: Potential for minimal harm
  • Scope: Many
• 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
• 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: 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: Some
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Potential for minimal harm
  • Scope: Some
• Exits that are accessible at all times
  • Harm: Potential for minimal harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • Harm: Potential for minimal harm
  • Scope: Many
• Store, cook, and serve food in a safe and clean way
  • 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
• 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: Many
• Construction that can resist fire for one hour or an approved fire extinguishing system
  • Harm: Potential for minimal harm
  • Scope: Many
• 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
• Keep all essential equipment working safely
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many