REGENCY MANOR - CHELAN, WA

Quality Measures

Complaint Deficiency

• Proper stairway enclosures and vertical shafts
  • 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
• 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
• Restrictions on the use of portable space heaters
  • 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: Some
• Hire sufficient dietary support personnel
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Restrictions on the use of portable space heaters
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Post nurse staffing information/data on a daily basis
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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: Minimal harm or potential for actual harm
  • Scope: Some
• Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• Signs that state that exit doors are to be kept closed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved installation, maintenance and testing program for fire alarm systems
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Few
• A two-hour-resistant firewall in common walls
  • 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: Some
• Did not have a written emergency evacuation plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 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: Some
• Exits that are free from obstructions and can be used at all times
  • 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: Many
• Honor all of the resident's rights as a resident of the nursing home, free of coercion and reprisal, and as a citizen or resident of the United States
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Minimal harm or potential for 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: Minimal harm or potential for actual harm
  • Scope: Some
• Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Reasonably accommodate the needs and preferences of each resident
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide a safe, clean, comfortable and homelike environment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide housekeeping and maintenance services
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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 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: Some
• 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
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for 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: Some
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide activities to meet the interests and needs of each resident
  • 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 necessary care and services to maintain the highest well being of each resident
  • Harm: Immediate jeopardy to resident health or safety
  • 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
• 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
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Proper facilities for the use and storage of combustible liquids
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Make sure that private space is available in the nursing home for resident groups or residents' families to meet
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide a safe, clean, comfortable and homelike environment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Provide housekeeping and maintenance services
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
• 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
• Provide care by qualified persons according to each resident's written plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients
  • 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: Actual harm
  • Scope: Few
• Make sure that residents receive treatment/services to not only continue, but improve the ability to care for themselves
  • 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 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
• Give the right treatment and services to residents who have mental or psychosocial problems adjusting
  • 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: Some
• Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give each resident enough fluids to keep them healthy and prevent dehydration
  • 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
• 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: Few
• Make sure that residents are safe from serious medication errors
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop policies and procedures for influenza and pneumococcal immunizations
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Have enough nurses to care for every resident in a way that maximizes the resident's well being
  • Harm: Immediate jeopardy to resident health or safety
  • Scope: Some
• Hire sufficient dietary support personnel
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
• 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
• Have a program that investigates, controls and keeps infection from spreading
  • Harm: Minimal harm or potential for actual 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

Staff Information