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HIGHLAND MANOR HEALTHCARE

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HIGHLAND MANOR HEALTHCARE VS
All other Nursing Homes USA
General
City INDIANAPOLIS   vs 0.3% Nursing Homes USA have INDIANAPOLIS
State attribute explanation IN   vs 3.1% Nursing Homes USA have IN
Street 2926 N CAPITOL AVE  
Zip Code 46208  
Phone 3179260254  
Overall Star Rating
(2.11 lower than average)
vs
3.11

Health Inspections Star Rating
(1.83 lower than average)
vs
2.83

Nurse Staffing Star Rating
(2.17 lower than average)
vs
3.17

Quality Measures Star Rating
(1.31 lower than average)
vs
3.31

RN Only Star Rating
(1.17 lower than average)
vs
3.17

Number of Certified Beds
52  (56.94 lower than average)
vs
108.94

Total Number of Residents
44  (47.25 lower than average)
vs
91.25

Percent of Occupied Beds
85 % (1.35 % higher than average)
vs
83.65 %

Health Survey Date 9/16/2011  
Fire Survey Date 9/22/2011  
Sprinkler Status Fully Sprinklered  vs 90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  vs 91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  vs 56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  vs 93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? No  vs 45.1% Nursing Homes USA don't have Multi Nursing Home Ownership?
Resident and Family Councils Both  vs 29.8% Nursing Homes USA have Both
Continuing Care Retirement Community? No  vs 90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? Yes  vs 31.3% Nursing Homes USA have Quality Indicator Survey?
Special Focus Facility? No  vs 99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
(54.16 lower than average)
vs
58.16

Total Enforcement Actions Count
(50.31 lower than average)
vs
56.31

# of deficiencies
28  (20.52 higher than average)
vs
7.48

Staff Information
Number of Residents
44  (47.38 lower than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.38  (0.39 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.2  (0.64 lower than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
0.58  (1.01 lower than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.06  (5.43 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.06  (0.04 lower than average)
vs
0.10

Environmental Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 4
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 09/04/2009
date Of Correction: 09/05/2009 

Mistreatment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 4
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 04/21/2011
date Of Correction: 06/07/2011 

Deficiency #2 Scope: Some
level Of Harm: 4
deficiency: 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.
survey Date: 04/21/2011
date Of Correction: 06/07/2011 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 08/27/2010
date Of Correction: 08/30/2010 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: 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.
survey Date: 08/27/2010
date Of Correction: 08/28/2010 

Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Give Each Resident A Notice Of Rights, Rules, Services And Charges. Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items And Services Medicaid Covers And Which The Resident Must Pay For.
survey Date: 12/15/2011
date Of Correction: 12/22/2011 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 08/27/2010
date Of Correction: 08/28/2010 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 07/22/2010
date Of Correction: 07/23/2010 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.
survey Date: 06/15/2010
date Of Correction: 07/06/2010 

Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Immediately Tell The Resident, The Resident's Doctor And A Family Member Of The Resident Of Situations (injury/decline/room, Etc.) That Affect The Resident.
survey Date: 06/15/2010
date Of Correction: 06/18/2010 

Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.
survey Date: 12/15/2011
date Of Correction: 12/22/2011 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Provide Medically-related Social Services To Help Each Resident Achieve The Highest Possible Quality Of Life.
survey Date: 04/21/2011
date Of Correction: 06/07/2011 

Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 08/27/2010
date Of Correction: 08/28/2010 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 08/05/2010
date Of Correction: 08/06/2010 

Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 06/15/2010
date Of Correction: 06/18/2010 

Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 06/15/2010
date Of Correction: 06/18/2010 

Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.
survey Date: 06/15/2010
date Of Correction: 06/18/2010 

Deficiency #8 Scope: Few
level Of Harm: 2
deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.
survey Date: 12/17/2009
date Of Correction: 12/18/2009 

Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 12/15/2011
date Of Correction: 12/22/2011 

Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 04/21/2011
date Of Correction: 06/07/2011 

Deficiency #3 Scope: Some
level Of Harm: 4
deficiency: Be Administered In An Acceptable Way That Maintains The Well-being Of Each Resident .
survey Date: 04/21/2011
date Of Correction: 06/07/2011 

Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 08/27/2010
date Of Correction: 08/30/2010 

Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 06/15/2010
date Of Correction: 06/16/2010 

Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 12/17/2009
date Of Correction: 12/18/2009 

Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.
survey Date: 06/15/2010
date Of Correction: 06/16/2010 

Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Offer Other Nutritional Food To Each Resident Who Will Not Eat The Food Served.
survey Date: 06/15/2010
date Of Correction: 07/02/2010 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Make Sure Menus Meet The Resident's Nutritional Needs And That There Is A Prepared Menu By Which Nutritious Meals Have Been Planned For The Resident And Followed.
survey Date: 06/15/2010
date Of Correction: 06/30/2010 

Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Provide A Tasty And Well-balanced Diet That Meets The Nutritional Needs Of Each Resident.
survey Date: 06/15/2010
date Of Correction: 07/02/2010 

Quality Measures Q1
Percent of long-stay residents whose need for help with daily activities has increased
75.2 % (42.25 % higher than average)
vs
32.95 %

Percent of long-stay residents who self-report moderate to severe pain
11.2-20 % (5.46 % lower than average)
vs
16.66 %

Percent of long-stay residents who lose too much weight
75.2 % (63.37 % higher than average)
vs
11.83 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
8.3 % (7.33 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection 2.6 / 3 % 
Percent of long-stay residents who have depressive symptoms
15.2 % (13.18 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained
75.2 % (31.52 % higher than average)
vs
43.68 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
40 % (44.64 % lower than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
45.5 % (38.44 % lower than average)
vs
83.94 %

Percent of short-stay residents who newly received an antipsychotic medication
(43.9 lower than average)
vs
45.90

Percent of long-stay residents experiencing one or more falls with major injury
5.3 % (10.22 % lower than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
13.6-28 % (11.79 % lower than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
75.2 % (51.5 % higher than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain
11.1 % (3 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
14.8 % (5.58 % higher than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
75.2 % (66.7 % higher than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
20.5 % (22.88 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
10.5 % (0.15 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
0.9 % (8.68 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
15.5 % (4.36 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
75.2 % (36.67 % higher than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
4.4 % (6.33 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
40.7 % (15.94 % higher than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
45.8 % (35.64 % lower than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
26.3 (79.3) % (48.45 % lower than average)
vs
74.75 %

Percent of short-stay residents who newly received an antipsychotic medication
3.4 % (13.94 % lower than average)
vs
17.34 %



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