| General |
| City |
| Mount Pleasant |
Kalamazoo |
| State attribute explanation |
| Mi |
Mi |
| Street |
| 1222 North Dr |
3057 Gull Road |
| Zip Code |
| 48,858 |
49,048 |
| Phone |
| 9,897,722,957 |
2,695,526,500 |
|
Overall Star Rating |
| 5 |
2 |
|
Health Inspections Star Rating |
| 5 |
1 |
|
Nurse Staffing Star Rating |
| 5 |
5 |
|
Quality Measures Star Rating |
| 4 |
4 |
|
RN Only Star Rating |
| 5 |
5 |
|
Number of Certified Beds |
| 100 |
121 |
|
Total Number of Residents |
| 98 |
94 |
|
Percent of Occupied Beds |
| 98 % |
78 % |
| Health Survey Date |
| 9/16/2011 |
6/8/2012 |
| Fire Survey Date |
| 9/16/2011 |
6/7/2012 |
| Sprinkler Status |
| Fully Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| Government - County |
Non Profit - Corporation |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| No |
No |
| Resident and Family Councils |
| Resident |
Resident |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| No |
No |
| Special Focus Facility? |
| No |
Yes |
| Civil Money Penalty Count |
| 75.2 |
7 |
| Total Enforcement Actions Count |
| 75.2 |
8 |
| # of deficiencies |
|
24 |
|
| Staff Information |
| Number of Residents |
| 98 |
94 |
| Number of RN Hours Per Resident Per Day |
| 1.2 |
1.38 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.62 |
0.66 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.82 |
2.04 |
| Number of CNA Hours Per Resident Per Day |
| 0.12 |
0.18 |
| Number Therapy Hours Per Resident Per Day |
| 0.12 |
0.18 |
| Environmental Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Safe, Easy To Use, Clean And Comfortable For Residents, Staff And The Public.survey Date: 10/14/2011date Of Correction: 11/11/2011 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 09/20/2011date Of Correction: 10/14/2011 |
| Deficiency #3 |
|
Scope: Somelevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 01/04/2010date Of Correction: 01/29/2010 |
| Mistreatment Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: 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.survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Deficiency #3 |
|
Scope: Fewlevel Of Harm: 4deficiency: Protect Each Resident From All Abuse, Physical Punishment, And Being Separated From Others.survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Resident Rights Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 4deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Deficiency #3 |
|
Scope: Fewlevel Of Harm: 4deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.survey Date: 08/27/2010date Of Correction: 11/04/2010 |
| Deficiency #4 |
|
Scope: Fewlevel Of Harm: 2deficiency: Reasonably Accommodate The Needs And Preferences Of Each Resident.survey Date: 03/16/2010date Of Correction: 04/09/2010 |
| Deficiency #5 |
|
Scope: Fewlevel Of Harm: 2deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.survey Date: 03/16/2010date Of Correction: 04/09/2010 |
| Quality Care Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 3deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 11/03/2011date Of Correction: 12/09/2011 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 4deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Deficiency #3 |
|
Scope: Fewlevel Of Harm: 4deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Deficiency #4 |
|
Scope: Fewlevel Of Harm: 4deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses.survey Date: 08/27/2010date Of Correction: 11/04/2010 |
| Deficiency #5 |
|
Scope: Fewlevel Of Harm: 4deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 08/27/2010date Of Correction: 11/04/2010 |
| Deficiency #6 |
|
Scope: Fewlevel Of Harm: 4deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.survey Date: 08/27/2010date Of Correction: 11/04/2010 |
| Resident Assessment Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional.survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional.survey Date: 03/16/2010date Of Correction: 04/09/2010 |
| Administration Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 4deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .survey Date: 06/10/2011date Of Correction: 07/15/2011 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 4deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .survey Date: 08/27/2010date Of Correction: 11/04/2010 |
| Pharmacy Service Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 4deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.survey Date: 08/27/2010date Of Correction: 11/04/2010 |
| Deficiency #2 |
|
Scope: Somelevel Of Harm: 2deficiency: Keep The Rate Of Medication Errors (wrong Drug, Wrong Dose, Wrong Time) To Less Than 5%.survey Date: 08/27/2010date Of Correction: 11/04/2010 |
| Nutrition and Dietary Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Prepare Food That Is Nutritional, Appetizing, Tasty, Attractive, Well-cooked, And At The Right Temperature.survey Date: 10/14/2011date Of Correction: 11/11/2011 |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 5.1 % |
8.1 / 8.8 |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 0.9 % |
1 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 10.8 % |
21 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 1.9 % |
8.3 % |
| Percent of long-stay residents who lose too much weight |
| 6.5 % |
6.3 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 56.3 % |
37.8 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 1.4 % |
1.50 % |
| Percent of long-stay residents with a urinary tract infection |
| 10.4 % |
3.2 % |
| Percent of long-stay residents who have depressive symptoms |
| 3.8 % |
21.9 % |
| Percent of long-stay residents who were physically restrained |
| 1.3 % |
75.2 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 17.6 % |
21.9 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 100 % |
98.2 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 98.2 % |
98.3 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 % |
1 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 5.1 % |
3.1 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 7.4 % |
6.3 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 0.8 % |
2.6 / 3 |
| Percent of long-stay residents who self-report moderate to severe pain |
| 12.5 % |
17.4 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 1.9 % |
6.3 % |
| Percent of long-stay residents who lose too much weight |
| 4.9 % |
10.1:1 |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 53.3 % |
39.3 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 1.6 % |
0.5 - 2.0 |
| Percent of long-stay residents with a urinary tract infection |
| 10.1:1 |
8.6:1 |
| Percent of long-stay residents who have depressive symptoms |
| 4.8 % |
19.3 % |
| Percent of long-stay residents who were physically restrained |
| 1.3 % |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 6.1 % |
1.50 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 18.3 % |
26.3 (79.3) |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 98.1 % |
98.1 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 97.5 % |
96 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 % |
9.7 % |