CAMBRIDGE SOUTH HEALTHCARE CTR (BEVERLY HILLS, MI) Detailed Nursing Home Profile

Quality Measures

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

This Nursing Home:	18.2%
State:	14.8%

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

Here:	3.5%
Michigan:	10.4%

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

This Nursing Home:	8.3%
Michigan:	6.3%

Percent of long-stay residents who lose too much weight

This Nursing Home:	8.2%
State:	7.4%

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

Here:	63.3%
Michigan:	48.3%

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

This Nursing Home:	2.2%
State:	4.0%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	5.5%
Michigan:	6.2%

Percent of long-stay residents who were physically restrained

Here:	4.0%
Michigan:	2.6%

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

Here:	2.7%
Michigan:	2.8%

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

Here:	88.7%
State:	92.5%

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

This Nursing Home:	88.0%
State:	94.6%

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

Here:	5.1%
State:	21.5%

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

This Nursing Home:	3.0%
State:	1.6%

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

Here:	86.2%
State:	84.1%

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

Here:	91.8%
State:	82.9%

Percent of long-stay residents who received an antipsychotic medication

Here:	8.6%
State:	16.0%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.570
State:	0.749

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

This Nursing Home:	0.790
Michigan:	0.782

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.350
State:	1.525

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	1.150
State:	0.109

Number Therapy Hours Per Resident Per Day

This Nursing Home:	1.150
Michigan:	0.112

Complaint Deficiency

Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- 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
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Signs that state that exit doors are to be kept closed
- 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
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Restrictions on the use of portable space heaters
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Restrictions on the use of portable space heaters
- 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
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: 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: Some
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: Some
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Actual harm
- Scope: Few
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide doctors orders for the resident's immediate care, at the time the resident was admitted
- 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
Protect a resident's right to refuse some types of non-requested transfers within the nursing home
- 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
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- 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
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: Many
1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- 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
Exits that are accessible at all times
- 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
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
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
A separate and independent backup electrical power source
- 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: Many
Proper stairway enclosures and vertical shafts
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Maintain comfortable and safe temperature levels
- 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
Give 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
- 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: Immediate jeopardy to resident health or safety
- Scope: Few
Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses
- 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: Some
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms
- Harm: Potential for minimal harm
- Scope: Some
1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- 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: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Rooms that can be unlocked from inside without a key
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper backup exit lighting
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Many
An approved automatic sprinkler system connected to the fire alarm system
- 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
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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: Some
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give 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
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- 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: Many
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms
- Harm: Potential for minimal harm
- Scope: Some
Make sure that a working call system is available in each resident's room or bathroom and bathing area
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
- Harm: Minimal harm or potential for actual harm
- Scope: Some

CAMBRIDGE SOUTH HEALTHCARE CTR - BEVERLY HILLS, MI

Quality Measures

Staff Information

Complaint Deficiency

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