HELEN NEWBERRY JOY HOSP LTCU (NEWBERRY, MI) Detailed Nursing Home Profile

Quality Measures

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

This Nursing Home:	20.5%
Michigan:	14.8%

Percent of long-stay residents who lose too much weight

Here:	9.8%
Michigan:	7.4%

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

This Nursing Home:	5.6%
Michigan:	4.0%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	14.6%
Michigan:	6.2%

Percent of long-stay residents who have depressive symptoms

Here:	32.4%
State:	4.8%

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

Here:	4.9%
State:	2.8%

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

Here:	92.7%
State:	92.5%

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

Here:	95.1%
State:	94.6%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	26.3%
Michigan:	16.0%

Complaint Deficiency

Proper medical gas storage and administration areas
- 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
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- 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
A two-hour-resistant firewall in common walls
- 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
A separate and independent backup electrical power source
- 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
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: Many
An approved automatic sprinkler system connected to the fire alarm system
- 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
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- 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
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
Provide housekeeping and maintenance services
- Harm: Potential for minimal harm
- Scope: Many
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
1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day
- Harm: Potential for minimal harm
- Scope: Many
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
Fire-resistant interior walls
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- 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: Few
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
An automatic smoke detection system in all hallways
- 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
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- 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: Few
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly working alarms on sprinkler valves
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide housekeeping and maintenance services
- 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
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- 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
Make sure that residents are safe from serious medication errors
- 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
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Potential for minimal harm
- Scope: Many
Have enough backup water supply for essential areas of the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Many

Process of Care

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

This Nursing Home:	98.0%
Michigan:	96.5%

Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics

This Nursing Home:	97.0%
Michigan:	97.1%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	67.0%
Michigan:	98.8%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

This Nursing Home:	87.0%
State:	95.7%

Percent of Patients Assessed and Given Influenza Vaccination

This Nursing Home:	60.0%
Michigan:	92.3%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	88.0%
State:	95.8%

Outcome of Care

30-Day Mortality Rates from Heart Failure

This Nursing Home:	12.0%
State:	10.8%

30-Day Mortality Rates from Pneumonia

This Nursing Home:	13.9%
Michigan:	11.4%

30-Day Readmission Rates from Heart Failure

This Nursing Home:	26.0%
Michigan:	25.2%

30-Day Readmission Rates from Pneumonia

Here:	19.8%
Michigan:	18.7%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.320
Michigan:	0.749

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

This Nursing Home:	1.550
Michigan:	0.782

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.870
Michigan:	1.525

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.130
Michigan:	0.109

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.130
State:	0.112

Use of Medical Imaging

Outpatients with low back pain who had an MRI without trying recommended treatments first, such as physical therapy.

Here:	51.100%
Michigan:	36.057%

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.

This Nursing Home:	5.800%
Michigan:	7.381%

Outpatient CT scans of the abdomen that were combination (double) scans.

Here:	0.149%
State:	0.111%

Outpatient CT scans of the chest that were combination (double) scans.

This Nursing Home:	0.135%
State:	0.051%

Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery

Here:	14.100%
Michigan:	5.222%

HELEN NEWBERRY JOY HOSP LTCU - NEWBERRY, MI