WEST MELBOURNE HEALTH AND REHABILITATION CENTER (WEST MELBOURNE, FL) Detailed Nursing Home Profile

Complaint Deficiency

Portable fire extinguishers
- 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
Properly installed electrical wiring and equipment
- 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
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
Proper construction of ducts through walls designed to prevent smoke passage
- 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: 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: Few
Automatic sprinkler systems that have been maintained in working order
- 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: Few
Proper medical gas storage and administration areas
- 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
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: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- 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
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
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 residents receive proper treatment and assistive devices to maintain their vision and hearing
- 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
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
Operate and provide services according to Federal, State, and local laws and professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Quickly tell the resident's doctor the results of lab tests
- 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: Few
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
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- 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: Some
Store, cook, and serve food in a safe and clean way
- 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
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- 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
Corridor and hallway doors that block smoke
- 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: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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: Few
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Try to resolve each resident's complaints quickly
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide access to a telephone for resident to use in private
- 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: 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
Make sure each resident has the right to have a choice over activities, their schedules and health care according to his or her interests, assessment, and plan of care
- 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 medically-related social services to help each resident achieve the highest possible quality of life
- 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
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: Few
Give the right treatment and services to residents who have mental or psychosocial problems adjusting
- 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
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
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 enough nurses to care for every resident in a way that maximizes the resident's well being
- 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: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Dispose of garbage and refuse properly
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide or obtain dental services for each resident
- 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
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
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
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.430
Florida:	0.628

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

Here:	0.860
State:	0.991

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.290
State:	1.617

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.090
State:	0.120

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.090
Florida:	0.122

Quality Measures

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

Here:	5.5%
Florida:	14.7%

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

Here:	14.3%
Florida:	8.4%

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

Here:	3.1%
State:	6.8%

Percent of long-stay residents who lose too much weight

Here:	1.5%
Florida:	8.1%

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

Here:	45.5%
State:	45.5%

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

This Nursing Home:	2.8%
State:	3.5%

Percent of long-stay residents with a urinary tract infection

Here:	9.9%
State:	9.2%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	1.6%
State:	3.4%

Percent of long-stay residents who were physically restrained

This Nursing Home:	3.8%
State:	2.8%

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

This Nursing Home:	4.5%
State:	2.8%

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

Here:	99.2%
State:	94.0%

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

Here:	100.0%
State:	95.6%

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

Here:	7.2%
Florida:	20.3%

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

This Nursing Home:	2.9%
Florida:	1.2%

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

Here:	86.8%
Florida:	86.5%

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

Here:	85.7%
Florida:	86.6%

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

This Nursing Home:	4.8%
State:	3.1%

Percent of long-stay residents who received an antipsychotic medication

Here:	39.2%
Florida:	24.1%

WEST MELBOURNE HEALTH AND REHABILITATION CENTER - WEST MELBOURNE, FL

Complaint Deficiency

Staff Information

Quality Measures

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