Deficiency Records for Harold and Grace Upjohn Community Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Harold and Grace Upjohn Community Care Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-20 | 2023-12-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-20 | 2023-12-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-11-20 | 2023-12-19 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-20 | 2023-12-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-12-19 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-11-20 | 2023-12-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-19 | 2023-05-26 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-19 | 2023-05-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-04-19 | 2023-05-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-19 | 2023-05-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-04-19 | 2023-05-26 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-19 | 2023-05-26 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-19 | 2023-05-26 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-19 | 2023-05-26 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-04-19 | 2023-05-26 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-19 | 2023-05-26 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-19 | 2023-05-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-19 | 2023-05-26 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-08-11 | 2022-09-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-08-11 | 2022-09-08 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-11 | 2022-09-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-11 | 2022-09-08 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-06-01 | 2022-06-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-01 | 2022-06-28 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-06-01 | 2022-06-28 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-06-01 | 2022-06-28 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-01-05 | 2022-02-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-05 | 2022-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-05 | 2022-02-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-01-05 | 2022-02-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-05 | 2022-02-14 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2022-01-05 | 2022-02-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-05 | 2022-02-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2022-01-06 | 2022-02-07 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-01-06 | 2022-02-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-06 | 2022-02-07 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-06 | 2022-02-07 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-01-06 | 2022-02-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-06 | 2022-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-06 | 2022-02-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-08-31 | 2021-09-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-31 | 2021-09-19 | Y |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-30 | 2021-09-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-05-06 | 2021-06-06 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-12-18 | 2020-02-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-12-18 | 2020-02-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-18 | 2020-02-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-12-19 | 2020-01-28 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-12-19 | 2020-01-28 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-19 | 2020-01-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-12-19 | 2020-01-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-19 | 2020-01-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-12-19 | 2020-01-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-12-19 | 2020-01-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-12-19 | 2020-01-28 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-12-19 | 2020-01-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-12-19 | 2020-01-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-12-19 | 2020-01-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-12-19 | 2020-01-28 | N |
