St Michaels Health & Rehab Center

Total Number of Beds: 110	Percent of Occupied Beds: 99%
Total Number of Residents: 109	Located Within a Hospital: No
Type of Ownership: Non profit - Church related	Multiple Nursing Homes by Same Owner: Yes
Councils the Nursing Home Participates in: Family & Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 12/10/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.16

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.61

Number of CNA Hours per Nursing Home Resident per Day: 2.35

Number of Staff Hours per Nursing Home Resident per Day: 3.12

Nursing Home Resident Information**:

Percent of Short-Stay Residents With Pressure Sores: 23%
Percent of High-Risk Residents Who Have Pressure Sores: 6%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 46%
Percent of Residents Who Have Moderate to Severe Pain: 6%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 3%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 1%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 4%
Percent of Residents Who are More Depressed or Anxious: 20%
Percent of Short-Stay Residents With Delirium: 10%
Percent of Residents Who Were Physically Restrained: 7%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 51%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 5%
Percent of Residents With a Urinary Tract Infection: 4%
** Details Last Reported on: 12/10/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2002-01-17	2002-02-26	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Isolated	Minimal harm or potential for actual harm
2002-01-17	2002-02-26	Environmental Deficiencies	Keep safe, clean and homelike surroundings.	Pattern	Potential for minimal harm
2002-01-17	2002-02-26	Pharmacy Service Deficiencies	Make sure that residents who have not taken antipsychotic drugs are not given these drugs, unless they are used to treat a problem that is diagnosed and noted in the medical record.	Isolated	Minimal harm or potential for actual harm
2002-01-17	2002-02-26	Pharmacy Service Deficiencies	Gradually lower the dose of residents' antipsychotic drugs, unless this causes negative medical effects.	Isolated	Minimal harm or potential for actual harm
2002-01-17	2002-02-26	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
2002-10-10	2002-11-13	Resident Assessment Deficiencies	Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
2002-10-10	2002-11-13	Resident Assessment Deficiencies	Check and update (if needed) each resident's assessment every 3 months.	Isolated	Minimal harm or potential for actual harm
2002-10-10	2002-11-19	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2002-10-10	2002-11-13	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Pattern	Minimal harm or potential for actual harm
2002-10-10	2002-11-07	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
2002-10-10	2002-11-19	Quality Care Deficiencies	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
2002-10-10	2002-11-19	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
2002-10-10	2002-11-07	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2002-10-10	2002-10-30	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Isolated	Minimal harm or potential for actual harm
2002-10-10	2002-11-19	Environmental Deficiencies	Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Resident Assessment Deficiencies	1) Develop a complete care plan within 7 days of each resident's admission; 2) prepare a care plan with the care team, including the primary nurse, doctor, resident or resident's family or representative; or 3) check and update the care plan.	Isolated	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Quality Care Deficiencies	Give professional services that follow each resident's written care plan.	Pattern	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Quality Care Deficiencies	Make sure that residents who cannot care for themselves receive help with eating/drinking, grooming and hygiene.	Isolated	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
2003-12-10	2004-01-19	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Isolated	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Quality Care Deficiencies	Prevent a loss in range of motion among residents who entered the nursing home with a full range of motion.	Isolated	Actual harm
2003-12-10	2004-01-19	Quality Care Deficiencies	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Quality Care Deficiencies	Make sure each resident is being watched and has assistance devices when needed, to prevent accidents.	Pattern	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Resident Assessment Deficiencies	Do a new assessment after any major change in a resident's physical or mental health.	Isolated	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Resident Assessment Deficiencies	Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
2003-12-10	2004-01-19	Resident Assessment Deficiencies	Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.