WEST HAVEN MANOR - APOLLO, PA

Complaint Deficiency

• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Back-up procedures in place for a faulty automatic sprinkler system
  • 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 each resident free from physical restraints, unless needed for medical treatment
  • 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 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: Some
• Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
  • 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: Some
• Provide doctors orders for the resident's immediate care, at the time the resident was admitted
  • Harm: Actual harm
  • Scope: Some
• 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: Actual harm
  • Scope: Some
• Provide proof that all residents' personal money which is deposited with the nursing home, is secure
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Restrictions on the use of flammable curtains
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Approved construction type or materials
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Properly working alarms on sprinkler valves
  • 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
• 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
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • 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: Many
• Exits that are accessible at all times
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• A fire alarm system that can be heard throughout the facility
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• An approved automatic sprinkler system connected to the fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Other fire safety features required by fire safety codes
  • Harm: Potential for minimal harm
  • Scope: Many
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Allow residents to easily view the results of the nursing home's most recent survey
  • Harm: Potential for minimal 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: 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
• Store, cook, and serve food in a safe and clean way
  • 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
• Corridor and hallway doors that block smoke
  • 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: 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: Some
• Properly located and lighted Exit signs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Record of quarterly fire drills for each shift under varying conditions
  • Harm: Potential for minimal harm
  • Scope: Some
• A fire alarm system that can be heard throughout the facility
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• An approved automatic sprinkler system connected to the fire alarm system
  • 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
• 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
• Reasonably accommodate the needs and preferences of each resident
  • 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
• 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
• Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
  • 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
• Store, cook, and serve food in a safe and clean way
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing
  • 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
• Keep all essential equipment working safely
  • 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: 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
• An approved automatic sprinkler system connected to the fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Portable fire extinguishers
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• Other fire safety features required by fire safety codes
  • Harm: Potential for minimal 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: 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
• Make sure that doctors visit residents regularly, as required
  • 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

Quality Measures

Staff Information