HAROLD AND GRACE UPJOHN COMMUN (KALAMAZOO, MI) Detailed Nursing Home Profile

Quality Measures

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

This Nursing Home:	3.8%
Michigan:	14.8%

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

This Nursing Home:	10.4%
State:	10.4%

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

Here:	8.8%
State:	6.3%

Percent of long-stay residents who lose too much weight

This Nursing Home:	7.5%
State:	7.4%

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

This Nursing Home:	55.9%
Michigan:	48.3%

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

Here:	1.2%
Michigan:	4.0%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	5.4%
State:	6.2%

Percent of long-stay residents who have depressive symptoms

Here:	4.4%
State:	4.8%

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

Here:	2.1%
Michigan:	2.8%

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

Here:	98.9%
State:	92.5%

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

Here:	98.9%
Michigan:	94.6%

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

This Nursing Home:	37.5%
Michigan:	21.5%

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

Here:	2.1%
State:	1.6%

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

Here:	92.3%
Michigan:	84.1%

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

Here:	92.3%
Michigan:	82.9%

Percent of short-stay residents who newly received an antipsychotic medication

Here:	1.4%
Michigan:	1.9%

Percent of long-stay residents who received an antipsychotic medication

Here:	6.5%
State:	16.0%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.940
Michigan:	0.749

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

This Nursing Home:	0.830
State:	0.782

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.770
State:	1.525

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.110
Michigan:	0.109

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.110
Michigan:	0.112

Complaint Deficiency

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
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: Immediate jeopardy to resident health or safety
- Scope: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Record of quarterly fire drills for each shift under varying conditions
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Portable fire extinguishers
- 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: Many
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
A separate and independent backup electrical power source
- 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: Some
Properly installed hallway dispensers for alcohol-based hand rub
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide a safe, clean, comfortable and homelike environment
- 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
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- 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: Some
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies and procedures for influenza and pneumococcal immunizations
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Ensure that all nurse aids who have worked less than 4 months are enrolled in appropriate training or have been deemed competent to provide nursing and nursing related services
- 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: Some
Did not have a written emergency evacuation plan
- 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: Few
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Restrictions on the use of highly flammable materials
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Proper medical gas storage and administration areas
- 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: Some
Properly installed hallway dispensers for alcohol-based hand rub
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Honor all of the resident's rights as a resident of the nursing home, free of coercion and reprisal, and as a citizen or resident of the United States
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies and procedures for influenza and pneumococcal immunizations
- 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
A two-hour-resistant firewall in common walls
- 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: 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
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Keep each resident's personal and medical records private and confidential
- 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: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- 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: Some
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- 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: Many

HAROLD AND GRACE UPJOHN COMMUN - KALAMAZOO, MI

Quality Measures

Staff Information

Complaint Deficiency

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