HALLMARK LIVING HOLLAND

Nursing Home Inspector

493 W 32ND ST
HOLLAND, MI 49423
Ottawa County
Phone: 616-396-1438
Provider Number: 235077
Last Inspection: 04/26/2017

About the Nursing Home

Number of Beds: 90
Number of Residents: 41
Beds Available: 49
Percent Occupancy: 46%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

31

Facility
22

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

31

2017
34

2016
33

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

4/26/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 6/2/2017
 
Failed To: 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. Isolated : Minimal 3 6/2/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 6/2/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 6/2/2017
 
Failed To: Give residents a notice of rights, rules, services and charges. Pattern : Potential 3 6/2/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 6/2/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/2/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 6/2/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 6/2/2017
 

3/10/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 4/26/2016
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 4/26/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/26/2016
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Isolated : Minimal 3 4/26/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 4/26/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 4/26/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 4/26/2016
 
Failed To: Have enough outside ventilation via a window or mechanical ventilation, or both. Pattern : Potential 3 4/26/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/26/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 4/26/2016
 

3/20/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 4/29/2015
 
Failed To: 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. Isolated : Minimal 3 4/29/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 4/29/2015
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Pattern : Minimal 4 4/29/2015
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 4/29/2015
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Isolated : Minimal 3 4/29/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 4/29/2015
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 4/29/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 4/29/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

3/1/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 3/23/2017
 
Failed To: Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. Isolated : Minimal 3 3/23/2017
 

2/18/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 3/18/2016
 

1/25/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect a residents' right to refuse some types of non-requested transfers within the nursing home. Isolated : Minimal 3 3/3/2016
 
Failed To: Provide timely notification to the resident before transfer or discharge. Isolated : Minimal 3 3/3/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 3/3/2016
 

11/3/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 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. Isolated : Minimal 3 12/10/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 12/10/2015
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Widespread : Minimal 5 12/10/2015
 

10/8/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Pattern : Minimal 4 11/16/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 11/16/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 11/16/2015
 

1/13/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 2/19/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 41 56.58 85.64
Registered Nurses 0.74 0.98 0.89
Licensed Practical / Vocational Nurses 0.53 0.74 0.84
Certified Nursing Assistants 2.57 2.62 2.54
Total Staff Hours 3.84 4.34 4.27

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% MI State Avg%
of high risk long-stay residents with pressure ulcers 1 2 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 97 96 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 95 95 92
of long-stay residents experiencing one or more falls with major injury 5 2 3
of long-stay residents who have depressive symptoms 1 2 2
of long-stay residents who lose too much weight 6 5 7
of long-stay residents who received an antianxiety or hypnotic medication 26 22 22
of long-stay residents who received an antipsychotic medication 14 13 12
of long-stay residents who self-report moderate to severe pain 4 5 6
of long-stay residents who were physically restrained 3 0 0
of long-stay residents whose ability to move independently worsened 13 15 17
of long-stay residents whose need for help with daily activities has increased 10 12 14
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 4 3 3
of low risk long-stay residents who lose control of their bowels or bladder 45 49 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 53 92 80
of short-stay residents who had an outpatient emergency department visit 11 11 11
of short-stay residents who made improvements in function 57 63 71
of short-stay residents who newly received an antipsychotic medication 2 0 1
of short-stay residents who self-report moderate to severe pain 12 13 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 63 91 79
of short-stay residents who were rehospitalized after a nursing home admission 20 17 21
of short-stay residents who were successfully discharged to the community 65 65 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0