Franciscan Health Michigan City
An acute care hospital in Michigan City, Indiana 46360
3500 Franciscan Way, Michigan City, Indiana 46360. (219) 879-8511.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 3of 5 CMS’s overall rating
- 4of 5 patient survey rating
- 2 deficiencies cited in the last three years
- 310 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Apr 2, 2026: a complaint inspection.
2 deficiencies cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
2 deficiencies in 2 months of the last 36. Last cited Apr 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Apr 2, 2026: complaint inspection1 deficiency
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Rn Supervision Of Nursing Care
The inspectors’ words, 170 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 35731 Based on document review and interview the registered nurse failed to complete/document an initial pain assessment in one (1) of ten (10) medical records (MR’s) reviewed. (Patient # 10) Findings include: 1. The facility policy titled, Assessment of Pain Guideline, PolicyStat ID: 19938471, indicated on page three (3) - Assessment - letter A - Initial Pain Assessment - patients are screened for pain by a licensed nurse upon admission. On page nine (9) - Documentation - letter A - Document all assessments/interventions on electronic health record. This policy was last revised on 03/11/2026. 2. Review of patient # 10’s medical record - lacked pain assessment documentation. 3. In interview with administrative staff member A # 4 (Manager Obstetrics) on 04/02/2026 at approximately 12:20 pm, confirmed N # 3 (Registered Nurse-RN) did not numerically assess/document patient # 10’s pain during his/her visit.”
Mar 19, 2024: complaint inspection1 deficiency
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Content Of Record
The inspectors’ words, 468 words
“CONTENT OF RECORD CFR(s): 482.24(c) The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient’s progress and response to medications and services. This Standard is not met as evidenced by: 14445 Based on document review and interview, staff failed to ensure complete and accurate documentation for follow through and communication for safe discharge plan for 1 of 10 MR’s (Medical Record) reviewed. (Patient # 3). Findings include: 1. Review of hospital policy titled: “Scope of Services - Case Management”, policy number: Policy Stat ID 14346827, under procedures/functions on page 2, indicated, case management to document discharge plan of care, and assessment of abuse reporting; for safe discharge. Last revised 12/2023. 2. Review of Patient # 3 MR, indicated the following: A. Patient; 85 year old, admitted to AH # 40 (Acute Care Hospital) to 4th floor - Medical unit on 2/15/2024; with diagnosis(es) of Infected sacral decubitus, with necrotic tissue, diabetes, obesity. B. Patient discharged to home with family and with HHC # 90 (Home health care) services on 2/22/2024. C. Social worker note by S # 12 (Social Worker - Case Management) on 2/16/2024 at 12:38 pm, reflected S # 12 met with FM # 4 (family member) at beside to discuss DCP (discharge plan). Patient’s daughters/sons live with her/him and provide care. FM # 4 stated that they have everything they need for DME (durable medical equipment). FM # 4 declined HHC (home health care) and SNF (skilled nursing facility) placement; even though it was strongly suggested since patient had very bad wounds. SW (social worker) and RN (Registered Nurse) have concerns after speaking with patient’s family member, that patient may not be getting cared for properly at home. APS (Adult Protective Services) will be contacted to follow. D. MR lacked any further documentation by Social Services - Case Management for the following: 1. Information for date/time APS contacted-report filed. 2. Any return call-contact from APS staff related to potential case; update on patient’s status and discharge plan. 3. Any further call-contact to APS staff for follow through; prior to patient’s discharge to home on 2/22/2024; for safe discharge home. 3. In interview on 3/19/2024 at approximately 1:20 pm, with S # 12, confirmed the following: A. Forgot to document about patient #3 APS report filed on 2/16/2024. B. Forgot to document call - contact with APS staff on 2/21/2024; that spoke with APS staff and that no case would be opened for patient #3. 4. In interview on 3/19/2024 at approximately 1:30 pm, with A # 2 (Manager - CM {Case Management}), A # 3 (Risk Specialist), and A # 7 (Clinical Informatics - Manager), confirmed that CM/SW notes lacked documentation for follow through with/for APS report and communication with APS prior to patient #3 discharge.”
All 5 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Apr 2, 2026 | Complaint inspection | 1 deficiency cited |
| Jan 14, 2026 | Complaint inspection | No deficiencies cited |
| Aug 21, 2025 | Complaint inspection | No deficiencies cited |
| Sep 26, 2024 | Complaint inspection | No deficiencies cited |
| Mar 19, 2024 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 3 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 7; safety of care, 0 better and 0 worse of 7; readmission, 0 better and 2 worse of 10.
- Patients rate it 4 of 5 in CMS’s patient survey (550 surveys completed, Oct 1, 2024 to Sep 30, 2025): 77% rated it 9 or 10 out of 10, and 73% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): central line bloodstream infections (CLABSI), no different than national benchmark; catheter urinary tract infections (CAUTI), no different than national benchmark; surgical site infections after colon surgery, no different than national benchmark; MRSA bloodstream infections, no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.7%, heart failure 11%, pneumonia 16.4%, COPD 9.3%, stroke 9.4%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 17.3%, heart failure 22.6%, pneumonia 17.3%, COPD 20.4%, hip or knee replacement 5.1%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after a colonoscopy, no different than the national rate; hospital admissions after outpatient chemotherapy, no different than the national rate; emergency visits after outpatient chemotherapy, no different than the national rate; unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 140 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 2% left before being seen.
- 80% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 0.99 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 3 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 4 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Jul 1, 1966.
- Ownership: voluntary non-profit - church.
- It is accredited by the Accreditation Commission for Health Care (ACHC), whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Voluntary non-profit - Church.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 2 deficiencies cited in the last three years came from inspections that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 4 of 5.
- 68% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- Franciscan Alliance Inc. owns 100% directly since Sep 19, 1974.
- 9 owners or officers are people: Stacey Colleen Leva (corporate officer, 100%); Stacey Colleen Leva (managing employee (on the payroll), 100%); Justin Kats (corporate officer, 100%); Justin Kats (managing employee (on the payroll), 100%); Brad Joubert (corporate director, 0%); Brad Joubert (managing employee (on the payroll), 0%); Kevin D Leahy (corporate officer, 0%); Kevin D Leahy (managing employee (on the payroll), 0%); Catherine C Nielsen (corporate director, 0%).
- CMS’s Provider of Services file records 1 change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| Franciscan Alliance Inc. | Owns 5% or more directly | 100% | Sep 19, 1974 |
How does it compare nearby?
- Of the 2 hospitals CMS lists in La Porte County, 2 have an overall star rating from CMS: 2 rated 3 of 5.
- CMS rates this one 3 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Northwest Health-La Porte | 3 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.