ST JAMES NURSING CENTER - DETROIT, MI

Staff Information

Quality Measures

Complaint Deficiency

• An approved installation, maintenance and testing program for fire alarm systems
  • 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: 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: Immediate jeopardy to resident health or safety
  • 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
• Restrictions on the use of portable space heaters
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
• 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: Few
• Exits that are accessible at all times
  • Harm: 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
• Exits that are accessible at all times
  • Harm: Actual harm
  • Scope: Few
• A fire alarm system that can be heard throughout the facility
  • 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
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Signs that state that exit doors are to be kept closed
  • Harm: Minimal harm or potential for actual harm
  • Scope: Many
• 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
• Automatic sprinkler systems that have been maintained in working order
  • 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
• Keep each resident free from physical restraints, unless needed for medical treatment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Review or revise the resident's care plan after any major change in a resident's physical or mental health
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • 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 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
• 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
• 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: Few
• 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: Few
• Corridor and hallway doors that block smoke
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
• Smoke barrier doors that can resist smoke for at least 20 minutes
  • 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: Some
• Exit stairways and towers that are smoke proof
  • 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
• Properly located and lighted Exit signs
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Did not have a written emergency evacuation plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• An approved automatic sprinkler system connected to the fire alarm system
  • 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
• Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly protected cooking facilities
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Restrictions on the use of flammable curtains
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Proper facilities for the use and storage of combustible liquids
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Properly installed electrical wiring and equipment
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• 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: Few
• Provide medically-related social services to help each resident achieve the highest possible quality of life
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Conduct initial and periodic assessments of each resident's functional capacity
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Provide care by qualified persons according to each resident's written plan of care
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Maintain 15 months of resident assessments in the resident's active clinical record
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
  • Harm: Immediate jeopardy to resident health or safety
  • 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
• Store, cook, and serve food in a safe and clean way
  • 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
• Corridors that are separated from common areas by walls constructed to limit the passage of 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
• 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
• Rooms that can be unlocked from inside without a key
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Did not have a written emergency evacuation plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• An approved automatic sprinkler system connected to the fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Other fire safety features required by fire safety codes
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Back-up procedures in place for a faulty automatic sprinkler system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• An approved back-up procedure for a faulty fire alarm system
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• 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
  • 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: Few
• Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
  • Harm: Minimal harm or potential for actual harm
  • Scope: Some
• Allow the resident the right to participate in the planning or revision of the resident's care plan
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Give the right treatment and services to residents who have mental or psychosocial problems adjusting
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few
• Make sure medically necessary lab services/tests are ordered by the attending physician
  • Harm: Minimal harm or potential for actual harm
  • Scope: Few