General Information: DEANWOOD REHABILITATION AND WELLNESS CENTER
Nursing home name DEANWOOD REHABILITATION AND WELLNESS CENTER
Address5000 BURROUGHS AVE. NE
WASHINGTON, DC 20019
Phone number (202) 399-7504
Located within a hospital No
Type of ownership For profit - Corporation
Owner operates multiple homesYes
Accept Medicare or Medicaid Medicare and Medicaid
Continue Care Retirement CommunityNo
Resident and family councils BOTH
Certified number of beds 296
Total number of residents 269
Perc of occupied beds 91
Sprinkler status Partial
Last health survey date 03/28/2012
Fire survey date: 03/29/2012
Ratings Summary: DEANWOOD REHABILITATION AND WELLNESS CENTER
Overall rating 2
2
Nursing Home Staffing 1
1
Registered Nurses only 1
1
Health Inspections 1
1
Quality Measures 5
5
Nursing Home Staffing Info: DEANWOOD REHABILITATION AND WELLNESS CENTER
National AverageDEANWOOD REHABILITATION AND WELLNESS CENTER
Overall staff rating Not Available. 1
1
Registered Nurses only rating Not Available 1
1
Total Number of Residents 88.1 269.00
Total Number of Licensed Nurse Staff Hours per Resident per Day 29.8 hours 1.63 hours
Registered Nurses Hours per Residents per Day 29.0 hours .36 hours
Licensed Practical or Vacation Nurses Hours per Resident per Day 29.0 hours 1.26 hours
Certified Nursing Assistants Hours per Residents per Day 29.0 hours .36 hours
Health Inpections: DEANWOOD REHABILITATION AND WELLNESS CENTER
Inspection Results: 03/28/2012
CorrectedCategoryDeficiencySeverity
06/19/2012Administration DeficienciesSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. F
06/19/2012Administration DeficienciesKeep accurate, complete and organized clinical records on each resident that meet professional standards. E
06/19/2012Environmental DeficienciesMake sure there is a pest control program to prevent/deal with mice, insects, or other pests. E
07/06/2012Environmental DeficienciesMake sure that a working call system is available in each resident's room or bathroom and bathing area. E
07/06/2012Environmental DeficienciesKeep all essential equipment working safely. F
07/06/2012Environmental DeficienciesHave a program that investigates, controls and keeps infection from spreading. F
07/06/2012Pharmacy Service DeficienciesMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. D
06/19/2012Pharmacy Service DeficienciesAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. D
06/19/2012Pharmacy Service DeficienciesProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. D
06/19/2012Resident Assessment DeficienciesMake sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. D
06/19/2012Nutrition and Dietary DeficienciesStore, cook, and serve food in a safe and clean way. D
06/19/2012Pharmacy Service DeficienciesEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. D
07/06/2012Environmental DeficienciesEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. E
07/06/2012Quality Care DeficienciesGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. D
06/19/2012Quality Care DeficienciesGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. G
07/06/2012Quality Care DeficienciesProvide necessary care and services to maintain or improve the highest well being of each resident. E
07/06/2012Quality Care DeficienciesEnsure services provided by the nursing facility meet professional standards of quality. D
06/19/2012Resident Assessment DeficienciesAllow residents the right to participate in the planning or revision of care and treatment. E
06/19/2012Resident Assessment DeficienciesDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E
06/19/2012Resident Assessment DeficienciesEnsure each resident receives an accurate assessment by a qualified health professional. E
06/19/2012Resident Assessment DeficienciesConduct initial and periodic assessments of each resident's functional capacity. D
06/19/2012Environmental DeficienciesMaintain comfortable and safe temperature levels. D
07/06/2012Environmental DeficienciesProvide housekeeping and maintenance services. E
07/06/2012Resident Rights DeficienciesGive notice to the resident before a room or roommate change. D
06/19/2012Resident Rights DeficienciesProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. D
06/19/2012Mistreatment DeficienciesDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. D
06/19/2012Mistreatment Deficiencies1) 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. D
06/19/2012Resident Rights DeficienciesPermit residents to remain in the facility and not be transferred or discharged without adequate reason. D
06/19/2012Resident Rights DeficienciesProvide residents with private access to a telephone. D
06/19/2012Resident Rights DeficienciesProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home. F
06/19/2012Resident Rights DeficienciesImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. D
06/19/2012Resident Rights DeficienciesGive residents a notice of rights, rules, services and charges. D
Inspection Results: 04/21/2011
CorrectedCategoryDeficiencySeverity
07/07/2011Administration DeficienciesSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. F
07/07/2011Administration DeficienciesKeep accurate, complete and organized clinical records on each resident that meet professional standards. D
07/07/2011Administration DeficienciesEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility D
07/07/2011Administration DeficienciesMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident. D
07/07/2011Environmental DeficienciesMake sure there is a pest control program to prevent/deal with mice, insects, or other pests. D
07/07/2011Environmental DeficienciesMake sure that a working call system is available in each resident's room or bathroom and bathing area. D
07/07/2011Environmental DeficienciesKeep all essential equipment working safely. E
07/07/2011Environmental DeficienciesHave a program that investigates, controls and keeps infection from spreading. J
07/27/2011Pharmacy Service DeficienciesMaintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. D
07/27/2011Nutrition and Dietary DeficienciesStore, cook, and serve food in a safe and clean way. E
07/07/2011Quality Care DeficienciesProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. D
07/07/2011Quality Care DeficienciesGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. D
07/07/2011Quality Care DeficienciesAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene. D
07/07/2011Quality Care DeficienciesMake sure that residents receive treatments/services to maintain or improve their ability to care for themselves. D
07/07/2011Quality Care DeficienciesProvide necessary care and services to maintain or improve the highest well being of each resident. D
07/07/2011Resident Assessment DeficienciesAllow residents the right to participate in the planning or revision of care and treatment. D
07/07/2011Resident Assessment DeficienciesDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. E
07/27/2011Environmental DeficienciesProvide housekeeping and maintenance services. E
07/07/2011Quality Care DeficienciesProvide medically-related social services to help each resident achieve the highest possible quality of life. D
07/07/2011Quality Care DeficienciesProvide activities to meet the interests and needs of each resident. D
07/07/2011Resident Rights DeficienciesUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party. D
07/07/2011Resident Rights DeficienciesGive residents a notice of rights, rules, services and charges. E
Inspection Results: 04/26/2010
CorrectedCategoryDeficiencySeverity
07/23/2010Administration DeficienciesKeep accurate, complete and organized clinical records on each resident that meet professional standards. D
07/23/2010Environmental DeficienciesKeep all essential equipment working safely. D
07/23/2010Environmental DeficienciesHave a program that investigates, controls and keeps infection from spreading. D
07/23/2010Quality Care DeficienciesGive specialized rehabilitative services that are medically necessary by qualified personnel, when ordered by a doctor. E
07/23/2010Resident Assessment DeficienciesMake sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. D
07/23/2010Nutrition and Dietary DeficienciesStore, cook, and serve food in a safe and clean way. D
07/23/2010Quality Care DeficienciesDevelop policies and procedures for influenza and pneumococcal immunizations. D
07/23/2010Pharmacy Service DeficienciesEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. D
07/23/2010Quality Care DeficienciesEnsure residents maintain acceptable nutritional status. D
07/23/2010Environmental DeficienciesEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. D
07/23/2010Quality Care DeficienciesProvide necessary care and services to maintain or improve the highest well being of each resident. E
07/23/2010Quality Care DeficienciesEnsure services provided by the nursing facility meet professional standards of quality. D
07/23/2010Resident Assessment DeficienciesAllow residents the right to participate in the planning or revision of care and treatment. D
07/23/2010Resident Assessment DeficienciesDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D
07/23/2010Resident Assessment DeficienciesEnsure each resident receives an accurate assessment by a qualified health professional. D
07/23/2010Resident Assessment DeficienciesAssure that each residentís assessment is updated at least once every 3 months. D
07/23/2010Environmental DeficienciesProvide housekeeping and maintenance services. D
07/23/2010Resident Rights DeficienciesProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. D
07/23/2010Resident Rights DeficienciesProvide residents with private access to a telephone. D
07/23/2010Resident Rights DeficienciesTry to resolve each resident's complaints quickly. D
07/23/2010Resident Rights DeficienciesKeep residents' personal and medical records private and confidential. D
07/23/2010Resident Rights DeficienciesUpon the death of a resident, convey the residentís personal funds and an accounting of those funds to the appropriate party. D

Fire Safety Inpections: DEANWOOD REHABILITATION AND WELLNESS CENTER
Inspection Results: 03/29/2012
CorrectedCategoryDeficiencySeverity
07/06/2012Miscellaneous DeficienciesOther fire safety features required by fire safety codes. E
07/06/2012Fire Alarm Systems DeficienciesAn approved installation, maintenance and testing program for fire alarm systems. E
07/06/2012Emergency Plans and Fire Drills DeficienciesRecord of quarterly fire drills for each shift under varying conditions. D
07/06/2012Corridor Walls and Doors DeficienciesCorridor and hallway doors that block smoke. E
07/06/2012Corridor Walls and Doors DeficienciesCorridors that are separated from use areas by walls constructed to limit the passage of smoke. E
Inspection Results: 05/05/2011
CorrectedCategoryDeficiencySeverity
07/05/2011Corridor Walls and Doors DeficienciesCorridor and hallway doors that block smoke. E
07/05/2011Fire Alarm Systems DeficienciesA properly located automatic smoke detector system in all hallways (new only). D
07/05/2011Illumination and Emergency Power DeficienciesProperly located and lighted "Exit" signs. D
07/05/2011Miscellaneous DeficienciesOther fire safety features required by fire safety codes. E
07/05/2011Corridor Walls and Doors DeficienciesCorridors that are separated from use areas by walls constructed to limit the passage of smoke. E
Inspection Results: 04/19/2010
CorrectedCategoryDeficiencySeverity
07/23/2010Miscellaneous DeficienciesOther fire safety features required by fire safety codes. E
07/23/2010Electrical DeficienciesWeekly inspections and monthly testing of generators. F
07/23/2010Fire Alarm Systems DeficienciesAn approved installation, maintenance and testing program for fire alarm systems. E
07/23/2010Emergency Plans and Fire Drills DeficienciesRecord of quarterly fire drills for each shift under varying conditions. E
07/23/2010Emergency Plans and Fire Drills DeficienciesA written emergency evacuation plan. E
07/23/2010Illumination and Emergency Power DeficienciesProper backup exit lighting. E
07/23/2010Corridor Walls and Doors DeficienciesCorridor and hallway doors that block smoke. E
07/23/2010Corridor Walls and Doors DeficienciesCorridors that are separated from use areas by walls constructed to limit the passage of smoke. E

Resident Complaints: DEANWOOD REHABILITATION AND WELLNESS CENTER
Date Complaint Substantiated: 02/04/2013
CorrectedCategoryDeficiencySeverity
03/07/2013Administration DeficienciesOperate and provide services according to Federal E
Date Complaint Substantiated: 01/17/2012
CorrectedCategoryDeficiencySeverity
03/06/2012Quality Care DeficienciesGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. G
Date Complaint Substantiated: 01/06/2012
CorrectedCategoryDeficiencySeverity
01/30/2012Administration DeficienciesKeep accurate D
01/30/2012Quality Care DeficienciesProvide necessary care and services to maintain or improve the highest well being of each resident. D
Date Complaint Substantiated: 11/08/2011
CorrectedCategoryDeficiencySeverity
12/12/2011Resident Rights DeficienciesEstablish and follow a written policy that permits a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. D
Date Complaint Substantiated: 07/19/2010
CorrectedCategoryDeficiencySeverity
08/20/2010Administration DeficienciesKeep accurate D
08/20/2010Administration DeficienciesEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility K
08/20/2010Administration DeficienciesMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident. K
08/20/2010Quality Care DeficienciesProvide necessary care and services to maintain or improve the highest well being of each resident. D
08/20/2010Quality Care DeficienciesProperly care for residents needing special services K
Date Complaint Substantiated: 07/09/2010
CorrectedCategoryDeficiencySeverity
08/20/2010Quality Care DeficienciesGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. D
Date Complaint Substantiated: 06/14/2010
CorrectedCategoryDeficiencySeverity
07/07/2010Resident Rights DeficienciesImmediately tell the resident D

Quality Measures: DEANWOOD REHABILITATION AND WELLNESS CENTER
Quality MeasuresNational AverageDEANWOOD REHABILITATION AND WELLNESS CENTER
Overall quality rating Not Available 5
5
Long-Stay Residents
Percent of long-stay residents whose need for help with daily activities has increased. 27% 28.199999999999999%
Percent of long-stay high-risk residents with pressure ulcers. 19% 8.8000000000000007%
Percent of long-stay residents who self-report moderate to severe pain. 22% 0.29999999999999999%
Percent of long-stay low-risk residents who lose control of their bowels or bladder 62% 56.299999999999997%
Percent of long-stay residents who have/had a catheter inserted and left in their bladder. 13% 2.2999999999999998%
Percent of long-stay residents who lose too much weight. 16% 5.5999999999999996%
Percent of long-stay residents who were physically restrained. 11% 0.40000000000000002%
Percent of long-stay residents with a urinary tract infection. 16% 2.3999999999999999%
Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine. 99% 83.200000000000003%
Percent of long-stay residents who received an antipsychotic medication. 31% 28.5%
Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine. 97% 88%
Percent of long-stay residents experiencing one or more falls with major injury. 12% 1.8999999999999999%
Percent of long-stay residents who have depressive symptoms. 16% 3.2000000000000002%
Short-Stay Residents
Percent of short-stay residents who self-report moderate to severe pain. 36% 0.80000000000000004%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine. 87% 21.100000000000001%
Percent of short-stay residents who newly received an antipsychotic medication. 27% 6.9000000000000004%
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine. 92% 21.100000000000001%
Percent of short-stay residents with Pressure ulcers that are new or worsened. 11% 1.2%
Severity Codes Explanation. Note: The higher the letter, the higher the severity.
AIsolated /Potential for minimal harm
BPattern /Potential for minimal harm
CWidespread /Potential for minimal harm
DIsolated /Minimal harm or potential for actual harm
EPattern /Minimal harm or potential for actual harm
FWidespread /Minimal harm or potential for actual harm
GIsolated /Actual harm
HPattern /Actual harm
IWidespread /Actual harm
JIsolated /Immediate jeopardy to resident health or safety
KPattern /Immediate jeopardy to resident health or safety
LWidespread /Immediate jeopardy to resident health or safety

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