A report on D.C. Village, undertaken after one resident of the city-run nursing home froze to death and another died by scalding, concludes that many residents are neglected, security is poor, housekeeping is substandard and there are too few trained staff members to give proper care.

District officials said yesterday that many improvements have been made since the consultants studied the home.

The report was written last October and released yesterday to The Washington Post under the D.C. Freedom of Information Act. It contains the findings of a seven-member team from Rehabilitation Care Consultants Inc., a Madison, Wis., firm that examined the 427-resident home last July through September.

Security was a serious problem, according to the report, a special concern because many of the home's residents are confused and wander. The consultants found that staff members paid little attention to door alarms, which ring when anyone walks through the door.

"We need to install a different kind of system," said Sue Brown, director of the District's Long-Term Care Administration. She is considering suggestions from Pinkerton security consultants to buy TV door monitors or electronic wrist or ankle bands for residents that would trigger door alarms.

A fence and gate have been installed since the death last Jan. 16 of Wilhelmina Franklin, 86, whose frozen body was not found for six hours after she was missed during a bed check.

Search policies have improved, Brown said, resulting in 60 people searching for a resident who wandered away from the facility in October. The woman was found in a ditch behind the home about four hours after she was reported missing, but Brown said the woman was shopping during most of her absence.

Brown said her department processed paper work last October to hire 10 security officers, to add to the original eight officers. Only three have been hired so far, she said, because of delays in the personnel process. Thirty nursing assistants also were trained by the Wisconsin Avenue Nursing Home in how to handle residents who wander, Brown added.

Air and water temperatures were not well controlled, the report found.

Resident George Spells was fatally scalded March 19 while attempting to bathe himself. The home had been cited earlier by District health inspectors for excessively hot water.

Brown said that the city had performed extensive repairs on the heating and plumbing systems and hired an outside engineering firm to give immediate help when problems arise.

The consultants found that residents of all ages and disabilities were mixed together.

"For example, younger paralyzed residents are scattered among units with disoriented and wandering residents, emotionally/developmentally disabled residents, medically ill residents, etc." Residents appeared to be segregated only by sex, except for a new children's unit, where residents are all under 22.

The consultants also found poor hygiene and grooming among the residents, but noted this situation improved.

Nursing care was missing for many residents, according to the report. ". . .Several unit day rooms appeared to warehouse residents in geri-chairs low chairs built for geriatric patients , placed in a semicircle within an austere, bare room."

Staff vacancies are a serious problem, both the consultants and District officials agree. Brown said yesterday the home had 94 of its 690 jobs vacant, including 46 nursing vacancies. The difficulty in recruiting and retaining nurses, whose average base pay is $24,995, forces the District to hire temporary help from nursing agencies.

"We'd rather have a contract nurse than none at all," said Brown, who said the District pays about $250,000 a year to three agencies for temporary nurses at D.C. Village. "This is not just a preferred area of employment."

To improve the problem, the District has begun programs with three nursing schools to allow students to work at the home, she said.

Few activities were held for residents, the report found. "D.C. Village staff consider the TV as a program for residents all too often," it states.

On several days, the home's calendar showed no activities were planned.

"We had inadequate patient activities," Brown said, adding that paper work has been submitted to hire five new activities aides.

Brown said nearly all of the departments at the home are being reorganized. "If you looked at the institution today from six months ago, it's like day and night," she said.

David E. Rivers, director of the Department of Human Services, said the District has spent $662,000 for physical improvements and staff training since problems surfaced at the home following the residents' deaths. "I'm much more comfortable that we've shored up D.C. Village," Rivers said. "We've had major improvements in delivering care to patients."

Others disagreed. "There are still a lot of the same problems," said Ann Hart, nursing home ombudsman for the District. "There was a fire in December from trash in a stairway, and it's a miracle no one was hurt."

Eighteen residents were evacuated during the Dec. 2 fire, which was caused by discarded "smoking materials," according to Brown. John Ross, a patient advocate, said he warned home officials in September that the cluttered stairway was a fire hazard. Home officials said they don't recall the warning.

"In an institution, you periodically have things left where they shouldn't be," said Brown of the stairway. "This was just an unfortunate incident." The residents were moved to another floor.

Fay Mays, director of the patient advocate and ombudsman program at the home, said she has seen "a few" physical changes in the facility. "To be honest, I haven't seen much of a change, but the halls are a little bit better," she said. "The staff still complains about how short-handed they are."

The consultants who wrote the report said they were not rehired after the report was issued, as they had expected to be.

"We had a clear understanding that we would undertake the job only if we had a long-term involvement to carry out the solutions and monitor to make sure lasting changes occurred," said Sandy Kaspar, a nurse and nursing home administrator who helped write the report.

"We agreed to come in and put our reputation and name on this for a systems overhaul," Kaspar said. "We worked hard to tell the staff we were there for the long term, not just another flash in the pan."

Brown said the contractors were mistaken about their role, but that they may be selected to work on patient admissions and other tasks.