WILLIAM HOOD DUNWOODY CARE CTR

Nursing Home Inspector

3500 WEST CHESTER PIKE
NEWTOWN SQUARE, PA 19073
Delaware County
Phone: 215-359-4401
Provider Number: 395329
Last Inspection: 08/31/2017

About the Nursing Home

Number of Beds: 81
Number of Residents: 74
Beds Available: 7
Percent Occupancy: 91%
Insurance Accepted: Medicare
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

22

Facility
19

County
23

PA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

22

2017
19

2016
24

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

8/31/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 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. Isolated : Minimal 3 10/30/2017
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Widespread : Minimal 5 10/30/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 10/9/2017
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 10/30/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 10/9/2017
 
Failed To: Make sure that doctors visit residents regularly, as required. Isolated : Minimal 3 10/30/2017
 

9/7/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 10/28/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 10/28/2016
 
Failed To: Give the right treatment and services to residents who display physical or psychosocial problems adapting to changes in circumstances. Isolated : Minimal 3 10/28/2016
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 10/28/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 10/28/2016
 
Failed To: Ensure 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. Isolated : Minimal 3 10/28/2016
 

7/27/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to self-administer drugs if determined safe. Isolated : Minimal 3 8/28/2015
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 8/28/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 8/28/2015
 
Failed To: Ensure 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. Isolated : Minimal 3 8/28/2015
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Widespread : Potential 4 8/19/2015
 
Failed To: At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. Isolated : Minimal 3 8/28/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 8/28/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

No Complaint Deficiencies Reported

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg PA State Avg
Number of Residents 74 119.00 110.03
Registered Nurses 1.34 1.06 0.94
Licensed Practical / Vocational Nurses 0.80 0.80 0.85
Certified Nursing Assistants 2.70 2.25 2.26
Total Staff Hours 4.84 4.11 4.05

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% PA State Avg%
of high risk long-stay residents with pressure ulcers 2 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 91 94
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 95 95
of long-stay residents experiencing one or more falls with major injury 7 4 3
of long-stay residents who have depressive symptoms 1 3 2
of long-stay residents who lose too much weight 7 7 7
of long-stay residents who received an antianxiety or hypnotic medication 19 21 22
of long-stay residents who received an antipsychotic medication 2 14 15
of long-stay residents who self-report moderate to severe pain 1 6 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 15 20 20
of long-stay residents whose need for help with daily activities has increased 10 16 15
of long-stay residents with a catheter inserted and left in their bladder 1 1 1
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 53 57 56
of short-stay residents assessed and appropriately given the pneumococcal vaccine 99 76 83
of short-stay residents who had an outpatient emergency department visit 4 10 10
of short-stay residents who made improvements in function 67 62 64
of short-stay residents who newly received an antipsychotic medication 0 2 1
of short-stay residents who self-report moderate to severe pain 4 16 15
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 96 78 82
of short-stay residents who were rehospitalized after a nursing home admission 12 21 20
of short-stay residents who were successfully discharged to the community 78 54 52
of short-stay residents with pressure ulcers that are new or worsened 0 0 0