THE LIGHTHOUSE AT ISHPEMING HEALTH AND REHAB

Nursing Home Inspector

435 STONEVILLE RD
ISHPEMING, MI 49849
Marquette County
Phone: 906-485-1073
Provider Number: 235349
Last Inspection: 10/27/2016

About the Nursing Home

Number of Beds: 122
Number of Residents: 74
Beds Available: 48
Percent Occupancy: 61%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
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

 

46

Facility
24

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

46

2016
35

2016
28

2015

Medicare Ratings

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

 

Details by Inspection Date

10/27/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
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 11/29/2016
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 11/29/2016
 
Failed To: Provide activities to meet the interests and needs of each resident. Isolated : Minimal 3 11/29/2016
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Pattern : Minimal 4 11/29/2016
 
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 11/29/2016
 
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 11/29/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 11/29/2016
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 11/29/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 12/21/2016
 
Failed To: Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. Isolated : Minimal 3 11/29/2016
 
Failed To: Make sure that doctors visit residents regularly, as required. Isolated : Minimal 3 11/29/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Isolated : Minimal 3 11/29/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 11/29/2016
 
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 11/29/2016
 

5/5/2016 Inspection

 
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 6/20/2016
 
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 6/20/2016
 
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 6/20/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 6/20/2016
 
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 6/20/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 6/20/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 6/20/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 6/20/2016
 
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 6/20/2016
 
Failed To: Have enough outside ventilation via a window or mechanical ventilation, or both. Widespread : Potential 4 6/20/2016
 

11/5/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 12/8/2015
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 12/8/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 12/8/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 12/8/2015
 
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 12/8/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Widespread : Minimal 5 12/8/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 12/8/2015
 
Failed To: Make sure each resident has 1) at least one window to the outside in a room; 2) a room at or above ground level; 3) adequate bedding; 4) furniture that meets the resident's needs; or 5) adequate closet space. Isolated : Minimal 3 12/8/2015
 

Complaint Investigation Deficiencies

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

8/23/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Immediate 5 8/29/2017
 
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 8/29/2017
 
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. Pattern : Minimal 4 8/29/2017
 

6/6/2017 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 7/7/2017
 
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 7/7/2017
 
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 7/7/2017
 
Failed To: Give notice to the resident before a room or roommate change. Isolated : Minimal 3 7/7/2017
 
Failed To: Provide activities to meet the interests and needs of each resident. Isolated : Minimal 3 7/7/2017
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 7/7/2017
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 7/7/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 7/7/2017
 
Failed To: Make sure that residents receive treatments/services to maintain or improve their ability to care for themselves. Isolated : Minimal 3 7/7/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 7/7/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 7/7/2017
 
Failed To: Ensure residents maintain acceptable nutritional status. Isolated : Minimal 3 7/7/2017
 
Failed To: Give each resident enough fluids to keep them healthy and prevent dehydration. Isolated : Minimal 3 7/7/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Widespread : Minimal 5 7/7/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Widespread : Minimal 5 7/7/2017
 
Failed To: Keep all essential equipment working safely. Isolated : Minimal 3 7/7/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 7/7/2017
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Widespread : Minimal 5 7/7/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Widespread : Minimal 5 7/7/2017
 

10/27/2016 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 9/9/2016
 

6/15/2016 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 7/11/2016
 

9/4/2015 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 10/20/2015
 
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 10/20/2015
 
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 9/29/2015
 
Failed To: Reasonably accommodate the needs and preferences of each resident. Pattern : Minimal 4 9/29/2015
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Pattern : Minimal 4 9/29/2015
 

6/12/2015 Investigation

 
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 7/3/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 7/3/2015
 

4/2/2015 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. Isolated : Minimal 3 4/20/2015
 
Failed To: Maintain 15 months of resident assessments in the resident's active clinical record. Widespread : Potential 4 4/20/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 74 93.25 85.64
Registered Nurses 0.44 0.76 0.89
Licensed Practical / Vocational Nurses 0.92 1.21 0.84
Certified Nursing Assistants 2.49 3.53 2.54
Total Staff Hours 3.85 5.50 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 7 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 98 98 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 85 95 92
of long-stay residents experiencing one or more falls with major injury 6 3 3
of long-stay residents who have depressive symptoms 15 5 2
of long-stay residents who lose too much weight 10 7 7
of long-stay residents who received an antianxiety or hypnotic medication 15 16 22
of long-stay residents who received an antipsychotic medication 25 16 12
of long-stay residents who self-report moderate to severe pain 8 9 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 22 20 17
of long-stay residents whose need for help with daily activities has increased 22 16 14
of long-stay residents with a catheter inserted and left in their bladder 5 3 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 47 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 89 86 80
of short-stay residents who had an outpatient emergency department visit 11 14 11
of short-stay residents who made improvements in function 69 78 71
of short-stay residents who newly received an antipsychotic medication 0 2 1
of short-stay residents who self-report moderate to severe pain 29 23 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 81 88 79
of short-stay residents who were rehospitalized after a nursing home admission 27 20 21
of short-stay residents who were successfully discharged to the community 34 42 56
of short-stay residents with pressure ulcers that are new or worsened 2 0 0