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WINDEMERE NURSING & REHAB CTR ON MARTHAS VINEYARD

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WINDEMERE NURSING & REHAB CTR ON MARTHAS VINEYARD VS
All other Nursing Homes USA
General
City OAK BLUFFS   vs 0% Nursing Homes USA have OAK BLUFFS
State attribute explanation MA   vs 2.8% Nursing Homes USA have MA
Street ONE HOSPITAL ROAD, PO BOX 1747  
Zip Code 2557  
Phone 5086966465  
Overall Star Rating
(1.89 higher than average)
vs
3.11

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

Nurse Staffing Star Rating
(1.83 higher than average)
vs
3.17

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

RN Only Star Rating
(1.83 higher than average)
vs
3.17

Number of Certified Beds
86  (22.94 lower than average)
vs
108.94

Total Number of Residents
57  (34.25 lower than average)
vs
91.25

Percent of Occupied Beds
66 % (17.65 % lower than average)
vs
83.65 %

Health Survey Date 10/7/2011  
Fire Survey Date 11/1/2011  
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
Type of Ownership Non Profit - Corporation  vs 18.7% Nursing Homes USA have Non profit - Corporation
Located Within a Hospital? No  vs 93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? No  vs 45.1% Nursing Homes USA don't 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
75.2  (17.04 higher than average)
vs
58.16

Total Enforcement Actions Count
75.2  (18.89 higher than average)
vs
56.31

# of deficiencies
(5.48 lower than average)
vs
7.48

Staff Information
Number of Residents
57  (34.38 lower than average)
vs
91.38

Number of RN Hours Per Resident Per Day
0.91  (0.14 higher than average)
vs
0.77

Number of LPN/LVN Hours Per Resident Per Day
0.8  (0.04 lower than average)
vs
0.84

Total Number of Licensed Staff Hours Per Resident Per Day
1.71  (0.12 higher than average)
vs
1.59

Number of CNA Hours Per Resident Per Day
0.1  (5.39 lower than average)
vs
5.49

Number Therapy Hours Per Resident Per Day
0.1  (equals average)
vs
0.10

Mistreatment Deficiencies
Deficiency #1 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: 07/08/2010
date Of Correction: 08/20/2010 

Administration Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: 1) Review The Work Of Each Nurse Aide Every Year; And 2) Give Regular In-service Training Based Upon These Reviews.
survey Date: 07/08/2010
date Of Correction: 08/20/2010 

Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
13.5 % (11.59 % 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
6.9 % (9.76 % lower than average)
vs
16.66 %

Percent of long-stay high-risk residents with pressure ulcers
7.1 % (5.48 % lower than average)
vs
12.58 %

Percent of long-stay residents who lose too much weight
7.5 % (4.33 % lower than average)
vs
11.83 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
75.2 % (59.57 % higher than average)
vs
15.63 %

Percent of long-stay residents with a urinary tract infection
15.1 % (1.64 % higher than average)
vs
13.46 %

Percent of long-stay residents who have depressive symptoms
3.7 % (24.68 % lower than average)
vs
28.38 %

Percent of long-stay residents who were physically restrained 5.6:1 % 
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
95 % (10.36 % higher than average)
vs
84.64 %

Percent of short-stay residents with Pressure ulcers that are new or worsened
95 % (11.06 % higher than average)
vs
83.94 %

Percent of long-stay residents experiencing one or more falls with major injury 5.6:1 % 
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication 16.3:1 % 
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
5.3 % (8.8 % lower than average)
vs
14.10 %

Percent of long-stay high-risk residents with pressure ulcers
6.8 % (2.42 % lower than average)
vs
9.22 %

Percent of long-stay residents who lose too much weight
9.3 % (0.8 % higher than average)
vs
8.50 %

Percent of long-stay low-risk residents who lose control of their bowels or bladder
80.8 % (37.42 % higher than average)
vs
43.38 %

Percent of long-stay residents who have had a catheter inserted and left in their bladder
0.7 % (9.95 % lower than average)
vs
10.65 %

Percent of long-stay residents with a urinary tract infection
11.1 % (1.52 % higher than average)
vs
9.58 %

Percent of long-stay residents who have depressive symptoms
2.4 % (17.46 % lower than average)
vs
19.86 %

Percent of long-stay residents who were physically restrained
6 % (32.53 % lower than average)
vs
38.53 %

Percent of long-stay residents experiencing one or more falls with major injury
6 % (4.73 % lower than average)
vs
10.73 %

Percent of short-stay residents who self-report moderate to severe pain
14 % (10.76 % lower than average)
vs
24.76 %

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
91.3 % (9.86 % higher than average)
vs
81.44 %

Percent of short-stay residents with Pressure ulcers that are new or worsened 12.1:1 % 
Percent of short-stay residents who newly received an antipsychotic medication
5.3 % (12.04 % lower than average)
vs
17.34 %



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