MANORCARE HEALTH SERVICES-PEWAUKEE

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General
City	WAUKESHA	vs	0% Nursing Homes USA have WAUKESHA
State attribute explanation	WI	vs	2.5% Nursing Homes USA have WI	compare WI Nursing Homes USA
Street	N26 W23977 WATERTOWN RD
Zip Code	53188
Phone	2625230933
Overall Star Rating	2 (1.11 lower than average)	vs	3.11	Compare similar Overall Star Rating (2)
Health Inspections Star Rating	1 (1.83 lower than average)	vs	2.83	Compare similar Health Inspections Star Rating (1)
Nurse Staffing Star Rating	2 (1.17 lower than average)	vs	3.17	Compare similar Nurse Staffing Star Rating (2)
Quality Measures Star Rating	5 (1.69 higher than average)	vs	3.31	Compare similar Quality Measures Star Rating (5)
RN Only Star Rating	4 (0.83 higher than average)	vs	3.17	Compare similar RN Only Star Rating (4)
Number of Certified Beds	120 (11.06 higher than average)	vs	108.94	Compare similar Number of Certified Beds (120)
Total Number of Residents	89 (2.25 lower than average)	vs	91.25	Compare similar Total Number of Residents (89)
Percent of Occupied Beds	74 % (9.65 % lower than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (74) %
Health Survey Date	9/15/2011
Fire Survey Date	9/19/2011
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	compare Medicare and Medicaid Nursing Homes USA
Type of Ownership	For Profit - Corporation	vs	56.7% Nursing Homes USA have For profit - Corporation	compare For profit - Corporation Nursing Homes USA
Located Within a Hospital?	No	vs	93.6% Nursing Homes USA don't have Located Within a Hospital?	Compare similar don't have Located Within a Hospital?
Multi Nursing Home Ownership?	Yes	vs	54.9% Nursing Homes USA 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?	No	vs	68.7% Nursing Homes USA don't have Quality Indicator Survey?
Special Focus Facility?	No	vs	99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count	1 (57.16 lower than average)	vs	58.16
Total Enforcement Actions Count	1 (55.31 lower than average)	vs	56.31
# of deficiencies	33 (25.52 higher than average)	vs	7.48

Staff Information
Number of Residents	89 (2.38 lower than average)	vs	91.38
Number of RN Hours Per Resident Per Day	0.94 (0.17 higher than average)	vs	0.77
Number of LPN/LVN Hours Per Resident Per Day	0.63 (0.21 lower than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	1.56 (0.03 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: Few level Of Harm: 3 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 09/20/2010 date Of Correction: 11/03/2010
Deficiency #2		Scope: Many level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 03/23/2010 date Of Correction: 04/23/2010
Deficiency #3		Scope: Few level Of Harm: 3 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 03/23/2010 date Of Correction: 04/23/2010
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents. survey Date: 08/13/2009 date Of Correction: 09/13/2009
Deficiency #5		Scope: Some level Of Harm: 1 deficiency: Provide Clean Bed And Bath Linens That Are In Good Condition. survey Date: 08/13/2009 date Of Correction: 09/13/2009

Mistreatment Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property. survey Date: 09/20/2010 date Of Correction: 11/03/2010
Deficiency #2		Scope: Some 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: 09/20/2010 date Of Correction: 11/03/2010
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: 05/06/2010 date Of Correction: 05/21/2010
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: 05/06/2010 date Of Correction: 05/21/2010
Deficiency #5		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: 03/23/2010 date Of Correction: 04/23/2010

Resident Rights Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Reasonably Accommodate The Needs And Preferences Of Each Resident. survey Date: 09/20/2010 date Of Correction: 11/03/2010
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Try To Resolve Each Resident's Complaints Quickly. survey Date: 09/20/2010 date Of Correction: 11/03/2010
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: 09/20/2010 date Of Correction: 11/03/2010
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Listen To The Resident Or Family Groups Or Act On Their Complaints Or Suggestions. survey Date: 08/13/2009 date Of Correction: 09/13/2009
Deficiency #5		Scope: Many level Of Harm: 1 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: 08/13/2009 date Of Correction: 09/13/2009

Quality Care Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 09/20/2010 date Of Correction: 11/03/2010
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 03/23/2010 date Of Correction: 04/23/2010
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: 03/23/2010 date Of Correction: 04/23/2010
Deficiency #4		Scope: Some level Of Harm: 2 deficiency: Provide Activities To Meet The Interests And Needs Of Each Resident. survey Date: 03/23/2010 date Of Correction: 04/23/2010
Deficiency #5		Scope: Few level Of Harm: 2 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 11/11/2009 date Of Correction: Not Available
Deficiency #6		Scope: Few level Of Harm: 2 deficiency: Make Sure That Residents Receive Treatment/services To Not Only Continue, But Improve The Ability To Care For Themselves. survey Date: 08/13/2009 date Of Correction: 09/13/2009
Deficiency #7		Scope: Few level Of Harm: 2 deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality. survey Date: 08/13/2009 date Of Correction: 09/13/2009

Resident Assessment Deficiencies
Deficiency #1		Scope: Some level Of Harm: 2 deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured. survey Date: 09/20/2010 date Of Correction: 11/03/2010
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Allow The Resident The Right To Participate In The Planning Or Revision Of The Resident's Care Plan. survey Date: 03/23/2010 date Of Correction: 04/23/2010

Administration Deficiencies
Deficiency #1		Scope: Some level Of Harm: 1 deficiency: Post Nurse Staffing Information/data On A Daily Basis. survey Date: 05/06/2010 date Of Correction: 05/21/2010
Deficiency #2		Scope: Some level Of Harm: 1 deficiency: Keep Clinical Record Information Safe, So That It Will Not Be Lost, Destroyed Or Used By The Wrong Person. survey Date: 03/23/2010 date Of Correction: 04/23/2010
Deficiency #3		Scope: Few level Of Harm: 2 deficiency: Give Or Get Quality Lab Services/tests In A Timely Manner To Meet The Needs Of Residents. survey Date: 03/23/2010 date Of Correction: 04/23/2010

Pharmacy Service Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 09/20/2010 date Of Correction: 11/03/2010
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 03/23/2010 date Of Correction: 04/23/2010
Deficiency #3		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: 03/23/2010 date Of Correction: 04/23/2010
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist. survey Date: 08/13/2009 date Of Correction: 09/13/2009
Deficiency #5		Scope: Few level Of Harm: 2 deficiency: Keep The Rate Of Medication Errors (wrong Drug, Wrong Dose, Wrong Time) To Less Than 5%. survey Date: 08/13/2009 date Of Correction: 09/13/2009

Nutrition and Dietary Deficiencies
Deficiency #1		Scope: Some level Of Harm: 1 deficiency: Prepare Food That Is Nutritional, Appetizing, Tasty, Attractive, Well-cooked, And At The Right Temperature. survey Date: 08/13/2009 date Of Correction: 09/13/2009

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication	6.6 % (18.49 % lower than average)	vs	25.09 %
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	75.2 % (58.54 % higher than average)	vs	16.66 %
Percent of long-stay high-risk residents with pressure ulcers	1.6 % (10.98 % lower than average)	vs	12.58 %
Percent of long-stay residents who lose too much weight	13.3 % (1.47 % higher than average)	vs	11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	70.3 % (25.76 % higher than average)	vs	44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	1.3 % (14.33 % lower than average)	vs	15.63 %
Percent of long-stay residents with a urinary tract infection	1.3 % (12.16 % lower than average)	vs	13.46 %
Percent of long-stay residents who have depressive symptoms	75.2 % (46.82 % higher 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 who self-report moderate to severe pain	5.6:1 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	83.5 % (1.14 % lower than average)	vs	84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	84.3 % (0.36 % higher than average)	vs	83.94 %
Percent of short-stay residents who newly received an antipsychotic medication	75.2 (29.3 higher than average)	vs	45.90
Percent of long-stay residents experiencing one or more falls with major injury	2.6 / 3 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication	8.1 / 8.8 %
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	75.2 % (61.1 % higher than average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	2.20 % (7.02 % lower than average)	vs	9.22 %
Percent of long-stay residents who lose too much weight	9.7 % (1.2 % higher than average)	vs	8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	63.9 % (20.52 % higher than average)	vs	43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	3.7 % (6.95 % lower than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	6.5 % (3.08 % lower than average)	vs	9.58 %
Percent of long-stay residents who have depressive symptoms	1.9 % (17.96 % 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	3.6 % (7.13 % lower than average)	vs	10.73 %
Percent of short-stay residents who self-report moderate to severe pain	7 % (17.76 % lower than average)	vs	24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	78.5 % (2.94 % lower than average)	vs	81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	83.5 % (8.75 % higher than average)	vs	74.75 %
Percent of short-stay residents who newly received an antipsychotic medication	3.7 % (13.64 % lower than average)	vs	17.34 %