Highpointe on Michigan Health Care Facility

Highpointe on Michigan Health Care Facility

1031 Michigan Avenue

Buffalo, NY 14203

(716) 748-3101

www.highpointeonmichigan.org/

Services: Baseline Services, Pediatric, Ventilator Dependent

Beds

Behavioral Intervention:
Pediatric:13
Pediatric Ventilator Dependent:7
Residential Health Care:270
Transitional Care Unit:
Ventilator Dependent:10
Total Number of Beds:300

Administrative

Ownership: Voluntary--Not for Profit Corporation

Operated by: Kaleida Health
100 High Street
Buffalo, NY 14203

Permanent Facility Identifier: 3182

Operating Certificate: 1401001N

Medicaid Certified

Medicare Certified

Medicare Number: 335834

Statistics

Employee Flu Vaccination Rate: 20%

Occupancy Rate: 95%

Nursing Home CMS Quality (Short Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
424Percentage of short-stay residents who self-report moderate to severe pain16.358466/1/2017
425Percentage of short-stay residents with pressure ulcers that are new or worsened2.221976/1/2017
426Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine82.113826/1/2017
430Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine80.887016/1/2017
434Percentage of short-stay residents who newly received an antipsychotic medication1.526716/1/2017
471Percentage of short-stay residents who made improvements in function67.900996/1/2017

Nursing Home CMS Quality (Long Stay)

Measure CodeMeasure DescriptionAverage ScoreFootnoteProcessing Date
401Percentage of long-stay residents whose need for help with daily activities has increased25.217391006/1/2017
402Percentage of long-stay residents who self-report moderate to severe pain4.146918006/1/2017
403Percentage of high risk long-stay residents with pressure ulcers10.817941006/1/2017
404Percentage of long-stay residents who lose too much weight5.769229006/1/2017
405Percentage of low risk long-stay residents who lose control of their bowels or bladder46.875000006/1/2017
406Percentage of long-stay residents with a catheter inserted and left in their bladder2.388850006/1/2017
407Percentage of long-stay residents with a urinary tract infection2.822582006/1/2017
408Percentage of long-stay residents who have depressive symptoms1.416121006/1/2017
409Percentage of long-stay residents who were physically restrained2.114801006/1/2017
410Percentage of long-stay residents experiencing one or more falls with major injury2.510042006/1/2017
411Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine96.666668006/1/2017
415Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine92.670681006/1/2017
419Percentage of long-stay residents who received an antipsychotic medication6.318081006/1/2017
451Percentage of long-stay residents whose ability to move independently worsened23.189938006/1/2017
452Percentage of long-stay residents who received an antianxiety or hypnotic medication11.819116006/1/2017

Complaints

Number of Standard Health Deficiencies:60
Number of Live Safety Code Deficiencies:19
Number of Total Deficiencies:79
Number of Deficiencies related to Actual Harm or Immediate Jeopardy:4
Percent of Total Deficiencies related to Actual Harm or Immediate Jeopardy :5
Total intakes received (last three years):162
Intakes received per 100 occupied beds (last three years):56.2
Percent of total intakes received that were facility self reported incidents (last three years):51
On-site complaint investigations (last three years):62
Complaint investigations resulting in citations (last three years):21
Complaint investigations resulting in citations per 100 occupied beds (last three years):7.3
Complaint Citations in deficiency category: Administration:2
Complaint Citations in deficiency category: Quality of Care:11
Complaint Citations in deficiency category: Resident Rights:5
Complaint Citations in deficiency category: Dietary Services:0
Complaint Citations in deficiency category: Physical Environment:1
Complaint Citations in deficiency category: Other Services:2
Complaint Citations across all deficiency categories (last three years):21

Enforcements

Survey DateDeficiency CategoryStipulation DateFine Assessed
4/17/2015 0:00Multiple Deficiencies1/13/201616000

Surveys

Initial Survey DateSurvey TypeTotal Visits Required
10/24/2016Complaint2
10/7/2013Certification2
11/26/2014Complaint1
12/10/2015Complaint2
12/3/2013Complaint2
3/13/2015Complaint2
4/17/2015Complaint2
4/7/2016Complaint2
6/23/2014Certification2
6/30/2015Certification2
7/21/2016Certification2
7/9/2014Complaint2
8/22/2014Complaint2

Citations

Inspection TypeDeficiencySeverityResidents AffectedDate citation corrected
HealthPROPER CARE & SERVICES FOR RESIDENT W/ NASO-GASTRIC TUBE211/23/2015
HealthPHYSICIAN RESPONSIBILITIES DURING VISITS211/27/2014
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS221/27/2014
HealthFACILITY PROVIDES DRUGS AND BIOLOGICALS211/27/2014
HealthDEVELOP COMPREHENSIVE CARE PLANS2112/2/2013
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS2112/2/2013
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE2112/2/2013
HealthRANGE OF MOTION TREATMENT AND SERVICES2112/2/2013
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS2112/2/2013
HealthDIGNITY2112/2/2013
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS2112/2/2013
LSCNO SMOKING SIGNS WHERE OXYGEN USED2212/2/2013
LSCPIPED-IN OXYGEN SYSTEM2212/2/2013
LSCMEDICAL GAS SYSTEM2212/2/2013
LSCHAZARDOUS AREAS - SEPARATION2212/2/2013
HealthPROVIDE NECESSARY CARE FOR HIGHEST PRACTICABLE WELL BEING2212/2/2013
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS2112/2/2013
LSCCORRIDOR DOORS2212/2/2013
LSCSMOKE PARTITION CONSTRUCTION2212/2/2013
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS2112/23/2016
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES212/5/2016
HealthINFLUENZA AND PNEUMOCOCCAL IMMUNIZATION215/10/2015
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES225/10/2015
HealthPROPER TREATMENT/CARE FOR SPECIAL CARE NEEDS425/11/2015
HealthGOVERNING BODY APPOINTS ADMIN; MANAGES FACILITY425/11/2015
HealthNOT EMPLOY PERSONS GUILTY OF ABUSE425/11/2015
HealthFACILITY IS FREE OF ACCIDENT HAZARDS425/11/2015
HealthESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION225/11/2015
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES216/5/2016
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM218/18/2014
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS228/18/2014
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS228/18/2014
HealthFACILITY IS FREE OF ACCIDENT HAZARDS228/18/2014
HealthFOOD PROPERLY PREPARED, PALATABLE, ETC.218/18/2014
LSCHAZARDOUS AREAS - SEPARATION228/18/2014
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS228/18/2014
LSCSPRINKLER SYSTEM MAINTENANCE228/18/2014
LSCEMERGENCY PLAN228/18/2014
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.218/18/2014
HealthRESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE218/28/2015
LSCSPRINKLER SYSTEM MAINTENANCE228/28/2015
LSCEXIT PARTITIONS228/28/2015
LSCHAZARDOUS AREAS - SEPARATION228/28/2015
LSCSMOKE PARTITION CONSTRUCTION228/28/2015
LSCDOORS IN FIRE AND SMOKE PARTITIONS228/28/2015
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS128/28/2015
LSCCORRIDOR WALLS228/28/2015
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS228/28/2015
HealthFACILITY ESTABLISHES INFECTION CONTROL PROGRAM218/28/2015
HealthRESIDENT RECEIVES NOTICE BEFORE ROOM/ROOMMATE CHANGE218/28/2015
LSCEMERGENCY PLAN228/28/2015
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS228/28/2015
HealthPROPER TREATMENT TO PREVENT/HEAL PRESSURE SORES218/28/2015
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS218/28/2015
HealthSERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN218/28/2015
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN218/28/2015
HealthDEVELOP COMPREHENSIVE CARE PLANS218/28/2015
HealthACCURACY OF ASSESSMENTS/COORDINATED WITH PROFESSIONALS218/28/2015
HealthSELF-DETERMINATION - RESIDENT MAKES CHOICES218/28/2015
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.228/28/2015
HealthINFORM RESIDENT OF SERVICES/CHARGES/LEGAL RIGHTS/ETC.128/28/2015
LSCMEDICAL GAS SYSTEM228/28/2015
HealthFACILITY IS FREE OF ACCIDENT HAZARDS219/19/2016
HealthINFORM OF ACCIDENTS/SIGNIFICANT CHANGES/TRANSFER/ETC.219/19/2016
HealthADL CARE PROVIDED FOR DEPENDENT RESIDENTS219/19/2016
LSCMEDICAL GAS SYSTEM229/19/2016
LSCCORRIDOR DOORS229/19/2016
HealthCLINICAL RECORDS MEET PROFESSIONAL STANDARDS219/19/2016
HealthPROPER LABELING OF DRUGS AND BIOLOGICALS219/19/2016
HealthSTORE/PREPARE/DISTRIBUTE FOOD UNDER SANITARY CONDITIONS219/19/2016
HealthMENUS MEET NUTRITIONAL NEEDS/PREPARATION IN ADVANCE/FOLLOWED229/19/2016
HealthRESIDENTS FREE FROM SIGNIFICANT MEDICATION ERRORS219/19/2016
HealthRANGE OF MOTION TREATMENT AND SERVICES219/19/2016
HealthDEVELOPMENT/PREPARE/REVIEW OF COMPREHENSIVE CARE PLAN219/19/2016
HealthDIGNITY229/19/2016
HealthPERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS219/19/2016
HealthDEVELOP COMPREHENSIVE CARE PLANS219/19/2016
HealthRIGHT TO REFUSE TREATMENT/RESEARCH; FORM ADVANCE DIRECTIVES219/30/2014