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MILLBROOK HEALTHCARE AND REHABILITATION CENTER

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MILLBROOK HEALTHCARE AND REHABILITATION CENTER VS
All other Nursing Homes USA
General
City Lancaster  vs 0.2% Nursing Homes USA have Lancaster
State attribute explanation TX   vs 7.6% Nursing Homes USA have TX
Street 1850 W PLEASANT RUN RD  
Zip Code 75146  
Phone 9722751900  
Overall Star Rating
(0.11 lower than average)
vs
3.11

Health Inspections Star Rating
(0.17 higher than average)
vs
2.83

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

Quality Measures Star Rating
(1.69 higher than average)
vs
3.31

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

Number of Certified Beds
124  (15.06 higher than average)
vs
108.94

Total Number of Residents
79  (12.25 lower than average)
vs
91.25

Percent of Occupied Beds
64 % (19.65 % lower than average)
vs
83.65 %

Health Survey Date 5/10/2012  
Fire Survey Date 5/9/2012  
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
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? 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
(57.16 lower than average)
vs
58.16

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

# of deficiencies
(0.52 higher than average)
vs
7.48

Staff Information
Number of Residents
79  (12.38 lower than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.32  (0.45 lower than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.75  (0.09 lower than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.07  (0.52 lower than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.07  (5.42 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.07  (0.03 lower than average)
vs
0.10

Environmental Deficiencies
Deficiency #1 Scope: Some
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: 03/05/2010
date Of Correction: 03/29/2010 

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: 03/05/2010
date Of Correction: 03/29/2010 

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: 03/05/2010
date Of Correction: 03/29/2010 

Deficiency #3 Scope: Some
level Of Harm: 3
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 03/05/2010
date Of Correction: 03/29/2010 

Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 3
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 03/05/2010
date Of Correction: 03/29/2010 

Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Make Sure That Nurse Aides Show They Have The Skills And Techniques To Be Able To Care For Residents' Needs.
survey Date: 03/05/2010
date Of Correction: 03/29/2010 

Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 2
deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.
survey Date: 03/05/2010
date Of Correction: 03/29/2010 

Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Prepare Food That Is Nutritional, Appetizing, Tasty, Attractive, Well-cooked, And At The Right Temperature.
survey Date: 03/05/2010
date Of Correction: 03/29/2010 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
33.3 % (8.21 % higher 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 17.1:1 % 
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
3.7 % (11.93 % lower than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection 5.6:1 % 
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 assessed and given, appropriately, the seasonal influenza vaccine
97.3 % (12.66 % higher than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
85.7 % (1.76 % 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
1.4 % (14.12 % lower than average)
vs
15.52 %

Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
25.4 % (0.01 % higher than average)
vs
25.39 %

Percent of long-stay residents whose need for help with daily activities has increased
0.8 % (22.9 % lower than average)
vs
23.70 %

Percent of long-stay residents who self-report moderate to severe pain
1.4 % (12.7 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
8.5 % (0.72 % lower than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
1.4 % (7.1 % lower than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
32.9 % (10.48 % lower than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
3.3 % (7.35 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
4.2 % (5.38 % lower than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
2 % (17.86 % 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
1.3 % (9.43 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
13 % (11.76 % lower than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
92.5 % (11.06 % higher than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
27.2 % (47.55 % lower than average)
vs
74.75 %

Percent of short-stay residents who newly received an antipsychotic medication
8.7 % (8.64 % lower than average)
vs
17.34 %



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