MICHIANA HEALTH AND REHABILITATION CENTER

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General
City	MISHAWAKA	vs	0% Nursing Homes USA have MISHAWAKA
State attribute explanation	IN	vs	3.1% Nursing Homes USA have IN	compare IN Nursing Homes USA
Street	1420 E DOUGLAS RD
Zip Code	46545
Phone	5743077200
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	5 (1.83 higher than average)	vs	3.17	Compare similar Nurse Staffing Star Rating (5)
Quality Measures Star Rating	2 (1.31 lower than average)	vs	3.31	Compare similar Quality Measures Star Rating (2)
RN Only Star Rating	5 (1.83 higher than average)	vs	3.17	Compare similar RN Only Star Rating (5)
Number of Certified Beds	100 (8.94 lower than average)	vs	108.94	Compare similar Number of Certified Beds (100)
Total Number of Residents	73 (18.25 lower than average)	vs	91.25	Compare similar Total Number of Residents (73)
Percent of Occupied Beds	73 % (10.65 % lower than average)	vs	83.65 %	Compare similar Percent of Occupied Beds (73) %
Health Survey Date	12/12/2011
Fire Survey Date	1/11/2012
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	RESIDENT	vs	66% Nursing Homes USA have RESIDENT
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	2 (54.31 lower than average)	vs	56.31
# of deficiencies	13 (5.52 higher than average)	vs	7.48

Staff Information
Number of Residents	73 (18.38 lower than average)	vs	91.38
Number of RN Hours Per Resident Per Day	1.23 (0.46 higher than average)	vs	0.77
Number of LPN/LVN Hours Per Resident Per Day	1.19 (0.35 higher than average)	vs	0.84
Total Number of Licensed Staff Hours Per Resident Per Day	2.42 (0.83 higher than average)	vs	1.59
Number of CNA Hours Per Resident Per Day	0.27 (5.22 lower than average)	vs	5.49
Number Therapy Hours Per Resident Per Day	0.27 (0.17 higher than average)	vs	0.10

Environmental Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading. survey Date: 05/30/2012 date Of Correction: 06/21/2012
Deficiency #2		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: 05/30/2012 date Of Correction: 06/21/2012

Mistreatment Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment. survey Date: 06/08/2011 date Of Correction: 07/01/2011

Resident Rights Deficiencies
Deficiency #1		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: 05/30/2012 date Of Correction: 06/21/2012
Deficiency #2		Scope: Some level Of Harm: 2 deficiency: Provide Enough Notice Before Discharging Or Transferring A Resident. survey Date: 02/23/2012 date Of Correction: 02/27/2012
Deficiency #3		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: 06/08/2011 date Of Correction: 07/01/2011

Quality Care Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Make Sure That Each Resident Who Enters The Nursing Home Without A Catheter Is Not Given A Catheter, And Receive Proper Services To Prevent Urinary Tract Infections And Restore Normal Bladder Function. survey Date: 05/30/2012 date Of Correction: 06/21/2012
Deficiency #2		Scope: Few level Of Harm: 2 deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores. survey Date: 05/30/2012 date Of Correction: 06/21/2012
Deficiency #3		Scope: Few level Of Harm: 3 deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident . survey Date: 08/24/2011 date Of Correction: 09/14/2011
Deficiency #4		Scope: Few level Of Harm: 2 deficiency: Provide Activities To Meet The Interests And Needs Of Each Resident. survey Date: 06/08/2011 date Of Correction: 07/01/2011

Resident Assessment Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Develop A Post-discharge Plan With The Resident And Family For The Resident's Care After Leaving The Nursing Home. survey Date: 04/16/2012 date Of Correction: 05/04/2012
Deficiency #2		Scope: Few level Of Harm: 3 deficiency: Make Sure That A Doctor Approves A Resident's Admission In Writing And That Each Resident Remains Under The Care Of A Doctor. survey Date: 04/27/2011 date Of Correction: 05/20/2011

Administration Deficiencies
Deficiency #1		Scope: Few level Of Harm: 2 deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards. survey Date: 05/30/2012 date Of Correction: 06/21/2012

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication	17.8:1 %
Percent of long-stay residents whose need for help with daily activities has increased	4.7 % (28.25 % lower 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	14.7:1 %
Percent of long-stay residents who lose too much weight	2.3 % (9.53 % lower than average)	vs	11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	6.7 % (8.93 % lower than average)	vs	15.63 %
Percent of long-stay residents with a urinary tract infection	11.6:1 %
Percent of long-stay residents who have depressive symptoms	9.8 % (18.58 % 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 who self-report moderate to severe pain	13.4 % (11.62 % lower than average)	vs	25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	84.6 % (0.04 % lower than average)	vs	84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	87.4 % (3.46 % higher than average)	vs	83.94 %
Percent of short-stay residents who newly received an antipsychotic medication	3.3 % (42.6 % lower than average)	vs	45.90 %
Percent of long-stay residents experiencing one or more falls with major injury	4.5 % (11.02 % lower than average)	vs	15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication	15.7 % (9.69 % lower than average)	vs	25.39 %
Percent of long-stay residents whose need for help with daily activities has increased	3.5 % (20.2 % lower than average)	vs	23.70 %
Percent of long-stay residents who self-report moderate to severe pain	9.3 % (4.8 % lower than average)	vs	14.10 %
Percent of long-stay high-risk residents with pressure ulcers	8.7 % (0.52 % lower than average)	vs	9.22 %
Percent of long-stay residents who lose too much weight	3.6 % (4.9 % lower than average)	vs	8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder	34.8 % (8.58 % lower than average)	vs	43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder	7.2 % (3.45 % lower than average)	vs	10.65 %
Percent of long-stay residents with a urinary tract infection	11.7 % (2.12 % higher than average)	vs	9.58 %
Percent of long-stay residents who have depressive symptoms	4.8 % (15.06 % 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	5.3 % (5.43 % lower than average)	vs	10.73 %
Percent of short-stay residents who self-report moderate to severe pain	20.8 % (3.96 % lower than average)	vs	24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine	87.8 % (6.36 % higher than average)	vs	81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened	89.9 % (15.15 % higher than average)	vs	74.75 %
Percent of short-stay residents who newly received an antipsychotic medication	2.9 % (14.44 % lower than average)	vs	17.34 %