BROOKHAVEN MEDICAL CARE FACILI

Nursing Home Inspector

1890 APPLE AVE
MUSKEGON, MI 49442
Muskegon County
Phone: 231-724-3500
Provider Number: 235204
Last Inspection: 11/02/2017

About the Nursing Home

Number of Beds: 120
Number of Residents: 90
Beds Available: 30
Percent Occupancy: 75%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Government - County
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

 

52

Facility
45

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

52

2017
41

2017
44

2016

Medicare Ratings

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

 

Details by Inspection Date

11/2/2017 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 12/8/2017
 
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 12/8/2017
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 12/8/2017
 
Failed To: Provide written records when a resident is transferred or discharged. Isolated : Minimal 3 12/8/2017
 
Failed To: Have enough outside ventilation via a window or mechanical ventilation, or both. Pattern : Minimal 4 12/8/2017
 
Failed To: Completely assess the resident at least every twelve months. Isolated : Minimal 3 12/8/2017
 
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 12/8/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 12/8/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 12/8/2017
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 12/8/2017
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 12/8/2017
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 12/8/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 12/8/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 12/8/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 12/8/2017
 

3/2/2017 Inspection

 
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 4/7/2017
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 4/7/2017
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Potential 3 4/7/2017
 
Failed To: Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. Pattern : Potential 3 4/7/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 4/7/2017
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Isolated : Minimal 3 4/7/2017
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Pattern : Potential 3 4/7/2017
 
Failed To: 1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews. Pattern : Potential 3 4/7/2017
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 4/7/2017
 
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 4/7/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/7/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 4/7/2017
 

3/9/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. Pattern : Minimal 4 4/18/2016
 
Failed To: Dispose of garbage and refuse properly. Pattern : Minimal 4 4/18/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 4/18/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 4/18/2016
 
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 4/18/2016
 
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 4/18/2016
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 4/18/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 4/18/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 4/18/2016
 
Failed To: Ensure that residents are safe from serious medication errors. Isolated : Minimal 3 4/18/2016
 
Failed To: Try to resolve each resident's complaints quickly. Isolated : Minimal 3 4/18/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 4/18/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 4/18/2016
 

Complaint Investigation Deficiencies

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

7/27/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to have visitors. Isolated : Minimal 3 8/27/2017
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 8/27/2017
 

6/15/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from all abuse, physical punishment, and involuntary separation from others. Isolated : Immediate 5 8/27/2017
 
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 8/27/2017
 
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 8/27/2017
 

1/5/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Isolated : Minimal 3 1/28/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 1/28/2017
 

9/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Isolated : Minimal 3 10/27/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 10/27/2016
 

7/28/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Protect each resident from mistreatment, neglect and misappropriation of personal property. Isolated : Minimal 3 8/16/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Actual 4 8/16/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 8/16/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Minimal 3 8/16/2016
 

6/9/2016 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 : Immediate 5 6/3/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 90 69.22 85.64
Registered Nurses 1.01 0.84 0.89
Licensed Practical / Vocational Nurses 0.66 0.71 0.84
Certified Nursing Assistants 2.62 2.56 2.54
Total Staff Hours 4.29 4.12 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 8 6 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 93 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 93 92 92
of long-stay residents experiencing one or more falls with major injury 5 3 3
of long-stay residents who have depressive symptoms 2 1 2
of long-stay residents who lose too much weight 9 9 7
of long-stay residents who received an antianxiety or hypnotic medication 20 18 22
of long-stay residents who received an antipsychotic medication 18 11 12
of long-stay residents who self-report moderate to severe pain 10 7 6
of long-stay residents who were physically restrained 1 0 0
of long-stay residents whose ability to move independently worsened 24 17 17
of long-stay residents whose need for help with daily activities has increased 17 14 14
of long-stay residents with a catheter inserted and left in their bladder 6 3 2
of long-stay residents with a urinary tract infection 5 5 3
of low risk long-stay residents who lose control of their bowels or bladder 66 50 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 82 85 80
of short-stay residents who had an outpatient emergency department visit 14 16 11
of short-stay residents who made improvements in function 65 75 71
of short-stay residents who newly received an antipsychotic medication 0 1 1
of short-stay residents who self-report moderate to severe pain 27 19 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 83 83 79
of short-stay residents who were rehospitalized after a nursing home admission 17 19 21
of short-stay residents who were successfully discharged to the community 53 58 56
of short-stay residents with pressure ulcers that are new or worsened 2 0 0