HAZEL I FINDLAY COUNTRY MANOR

Nursing Home Inspector

1101 S SCOTT RD
SAINT JOHNS, MI 48879
Clinton County
Phone: 989-224-8936
Provider Number: 235602
Last Inspection: 12/14/2016

About the Nursing Home

Number of Beds: 157
Number of Residents: 125
Beds Available: 32
Percent Occupancy: 80%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non 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

 

43

Facility
37

County
31

MI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

43

2016
9

2016
23

2014

Medicare Ratings

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

 

Details by Inspection Date

12/14/2016 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 1/20/2017
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 1/20/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 1/20/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Potential 3 1/20/2017
 
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 1/20/2017
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 1/20/2017
 
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 1/20/2017
 
Failed To: Keep all essential equipment working safely. Widespread : Potential 4 1/20/2017
 
Failed To: Post nurse staffing information/data on a daily basis. Pattern : Minimal 4 1/20/2017
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 1/20/2017
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Pattern : Minimal 4 1/20/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 1/20/2017
 

1/14/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 2/19/2016
 
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 2/19/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 2/19/2016
 

11/7/2014 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 12/5/2014
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 12/5/2014
 
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 12/5/2014
 
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Isolated : Minimal 3 1/23/2015
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Widespread : Potential 4 12/5/2014
 
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 12/5/2014
 
Failed To: Ensure that all full-time nurse aids employed for more than 4 months are fully trained and competent to provide nursing and nursing-related services, as defined by Federal requirements. Widespread : Potential 4 12/5/2014
 

Complaint Investigation Deficiencies

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

9/14/2016 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 : Immediate 5 10/27/2016
 
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. Pattern : Minimal 4 10/14/2016
 
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. Pattern : Minimal 4 10/27/2016
 
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 10/14/2016
 
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Pattern : Minimal 4 10/27/2016
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Widespread : Minimal 5 10/27/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Immediate 5 10/14/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Widespread : Minimal 5 10/14/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Pattern : Potential 3 10/27/2016
 

10/2/2015 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 10/30/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 10/30/2015
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 10/30/2015
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Isolated : Minimal 3 10/30/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg MI State Avg
Number of Residents 125 80.33 85.64
Registered Nurses 0.65 1.07 0.89
Licensed Practical / Vocational Nurses 0.65 0.67 0.84
Certified Nursing Assistants 3.69 2.47 2.54
Total Staff Hours 4.99 4.20 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 3 4 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 95 92
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 91 92
of long-stay residents experiencing one or more falls with major injury 2 3 3
of long-stay residents who have depressive symptoms 6 4 2
of long-stay residents who lose too much weight 11 8 7
of long-stay residents who received an antianxiety or hypnotic medication 18 18 22
of long-stay residents who received an antipsychotic medication 19 12 12
of long-stay residents who self-report moderate to severe pain 9 8 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 14 17 17
of long-stay residents whose need for help with daily activities has increased 15 13 14
of long-stay residents with a catheter inserted and left in their bladder 2 2 2
of long-stay residents with a urinary tract infection 7 6 3
of low risk long-stay residents who lose control of their bowels or bladder 58 43 50
of short-stay residents assessed and appropriately given the pneumococcal vaccine 90 90 80
of short-stay residents who had an outpatient emergency department visit 15 14 11
of short-stay residents who made improvements in function 82 79 71
of short-stay residents who newly received an antipsychotic medication 1 0 1
of short-stay residents who self-report moderate to severe pain 21 26 16
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92 90 79
of short-stay residents who were rehospitalized after a nursing home admission 26 27 21
of short-stay residents who were successfully discharged to the community 57 55 56
of short-stay residents with pressure ulcers that are new or worsened 0 0 0