Deficiency Records for Harold and Grace Upjohn Community Care Center
Updated as of June 01, 2018
This is not the most recent data for Harold and Grace Upjohn Community Care Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-04-05 | 2018-04-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-05 | 2018-04-15 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-03-22 | 2018-04-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-22 | 2018-04-15 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-03-02 | 2018-04-15 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2018-03-02 | 2018-04-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-03-02 | 2018-04-15 | Y |
| Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source | Health | 2018-03-02 | 2018-04-15 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-03-02 | 2018-04-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-03-02 | 2018-04-15 | Y |
| 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 | 2018-03-02 | 2018-04-15 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2018-03-02 | 2018-04-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-03-02 | 2018-04-15 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-03-02 | 2018-04-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-03-02 | 2018-04-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-03-02 | 2018-04-15 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-03-02 | 2018-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-03-02 | 2018-04-15 | Y |
| Have a correctly designed non-healthcare occupancy area in a health care facility. | Fire Safety | 2017-08-31 | 2017-09-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2017-08-31 | 2017-09-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2017-08-31 | 2017-09-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2017-08-30 | 2017-09-22 | N |
| Try to resolve each resident's complaints quickly. | Health | 2017-08-30 | 2017-09-22 | N |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-08-30 | 2017-09-22 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-08-30 | 2017-09-22 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-30 | 2017-09-22 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-08-30 | 2017-09-22 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2017-08-30 | 2017-09-22 | N |
| 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. | Health | 2017-08-30 | 2017-09-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-30 | 2017-09-22 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-30 | 2017-09-22 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-30 | 2017-09-22 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-08-30 | 2017-09-22 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2017-07-26 | 2017-09-01 | Y |
| Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. | Health | 2017-07-26 | 2017-09-01 | Y |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2017-02-22 | 2017-04-12 | Y |
| 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. | Health | 2017-02-22 | 2017-03-17 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-02-22 | 2017-03-17 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-02-22 | 2017-03-17 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-09-15 | 2016-11-22 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-09-15 | 2016-11-22 | Y |
| A two-hour-resistant firewall separation. | Fire Safety | 2016-09-15 | 2016-11-15 | N |
| Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. | Fire Safety | 2016-09-15 | 2016-11-03 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-09-15 | 2016-11-03 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-09-15 | 2016-11-03 | N |
| A fire alarm system that can be heard throughout the facility. | Fire Safety | 2016-09-15 | 2016-11-03 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-09-15 | 2016-10-24 | N |
| Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. | Health | 2016-09-15 | 2016-10-24 | N |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-09-15 | 2016-10-24 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2016-09-15 | 2016-10-24 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-09-15 | 2016-10-24 | N |
| 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. | Health | 2016-09-15 | 2016-10-24 | Y |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2016-09-15 | 2016-10-24 | Y |
| Provide housekeeping and maintenance services. | Health | 2016-09-15 | 2016-10-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-09-15 | 2016-10-24 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-09-15 | 2016-10-24 | Y |
| Corridor and hallway doors that block smoke. | Fire Safety | 2015-09-17 | 2015-10-15 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-09-17 | 2015-10-15 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2015-09-17 | 2015-10-15 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2015-09-17 | 2015-10-15 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-09-17 | 2015-10-15 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2015-09-17 | 2015-10-15 | N |
| 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. | Health | 2015-08-28 | 2015-10-01 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2015-08-28 | 2015-10-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2015-08-28 | 2015-10-01 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2015-08-28 | 2015-10-01 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2015-08-28 | 2015-10-01 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2015-08-28 | 2015-10-01 | N |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2015-08-28 | 2015-10-01 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2015-08-28 | 2015-10-01 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-08-28 | 2015-10-01 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2015-08-28 | 2015-10-01 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-08-28 | 2015-10-01 | N |
| Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2015-08-28 | 2015-10-01 | N |
| 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. | Health | 2015-08-28 | 2015-10-01 | Y |
