RIVERVIEW REHABILITATION AND HEALTH CENTER (BALTIMORE, MD) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

This Nursing Home:	19.4%
State:	20.0%

Percent of long-stay residents who self-report moderate to severe pain

Here:	2.4%
State:	6.2%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	4.8%
Maryland:	7.7%

Percent of long-stay residents who lose too much weight

Here:	0.7%
State:	6.0%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Nursing Home:	58.7%
State:	56.8%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	1.6%
State:	3.1%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	1.1%
State:	6.0%

Percent of long-stay residents who were physically restrained

Here:	1.1%
State:	1.3%

Percent of long-stay residents experiencing one or more falls with major injury

Here:	5.8%
Maryland:	2.7%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	91.5%
State:	95.1%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	91.6%
State:	95.2%

Percent of short-stay residents who self-report moderate to severe pain

This Nursing Home:	14.7%
State:	16.5%

Percent of short-stay residents with Pressure ulcers that are new or worsened

Here:	1.5%
State:	1.3%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

This Nursing Home:	87.5%
State:	86.6%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	87.1%
Maryland:	85.7%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	5.2%
State:	2.8%

Percent of long-stay residents who received an antipsychotic medication

Here:	24.0%
State:	19.2%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.560
State:	0.759

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.880
Maryland:	0.899

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.440
State:	1.649

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.120
Maryland:	0.108

Number Therapy Hours Per Resident Per Day

Here:	0.120
State:	0.112

Complaint Deficiency

Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Hire sufficient dietary support personnel
- 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: 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
Signs that state that exit doors are to be kept closed
- 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: 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
Other fire safety features required by fire safety codes
- 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
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
Hire sufficient dietary support personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide special eating equipment and utensils for each resident who needs them
- 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
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
Properly installed electrical wiring and equipment
- 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
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
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
- 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: 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: Few
Restrictions on the use of portable space heaters
- 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
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
Provide care by qualified persons according to each resident's written plan of care
- 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: Some
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide proper discharge planning and communication, of the resident's health status and summary of the resident's stay
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Potential for minimal harm
- Scope: Some
Dispose of garbage and refuse properly
- Harm: Potential for minimal 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: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exit stairways and towers that are smoke proof
- 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
Properly installed electrical wiring and equipment
- 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: 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
Check and assess each resident's assessment at least every 3 months
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure each resident receives an accurate assessment by a qualified health professional
- 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
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
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: Potential for minimal harm
- Scope: Many
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give or get quality lab services/tests in a timely manner to meet the needs of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- 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: Some
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
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
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
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
Make sure that special or therapeutic diets are ordered by the attending doctor
- 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
Make sure that a doctor approves a resident's admission in writing and that each resident remains under the care of a doctor
- 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
Exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors
- 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
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
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- 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: Minimal harm or potential for actual harm
- Scope: Few
Make sure each resident receives an accurate assessment by a qualified health professional
- 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
Make sure services provided by the nursing facility meet professional standards of quality
- 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
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
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Corridor and hallway doors that block smoke
- Harm: Potential for minimal harm
- Scope: Many
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Some
Portable fire extinguishers
- Harm: Potential for minimal harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Potential for minimal harm
- Scope: Many
Proper medical gas storage and administration areas
- Harm: Potential for minimal harm
- Scope: Some

RIVERVIEW REHABILITATION AND HEALTH CENTER - BALTIMORE, MD

Quality Measures

Staff Information

Complaint Deficiency

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