| General |
| City |
| Waukesha |
Kenosha |
| State attribute explanation |
| Wi |
Wi |
| Street |
| 1810 Kensington Dr |
3415 N Sheridan Rd |
| Zip Code |
| 53,188 |
53,140 |
| Phone |
| 2,625,481,400 |
2,626,576,175 |
|
Overall Star Rating |
| 2 |
3 |
|
Health Inspections Star Rating |
| 2 |
2 |
|
Nurse Staffing Star Rating |
| 3 |
4 |
|
Quality Measures Star Rating |
| 4 |
3 |
|
RN Only Star Rating |
| 3 |
4 |
|
Number of Certified Beds |
| 170 |
159 |
|
Total Number of Residents |
| 145 |
86 |
|
Percent of Occupied Beds |
| 85 % |
54 % |
| Health Survey Date |
| 4/2/2012 |
1/19/2012 |
| Fire Survey Date |
| 3/30/2012 |
1/17/2012 |
| Sprinkler Status |
| Partially Sprinklered |
Fully Sprinklered |
| Program Participation |
| Medicare And Medicaid |
Medicare And Medicaid |
| Type of Ownership |
| Non Profit - Other |
For Profit - Corporation |
| Located Within a Hospital? |
| No |
No |
| Multi Nursing Home Ownership? |
| Yes |
Yes |
| Resident and Family Councils |
| Resident |
Resident |
| Continuing Care Retirement Community? |
| No |
No |
| Quality Indicator Survey? |
| No |
No |
| Special Focus Facility? |
| No |
No |
| Civil Money Penalty Count |
| 75.2 |
6 |
| Total Enforcement Actions Count |
| 75.2 |
7 |
| # of deficiencies |
| 20 |
19 |
|
| Staff Information |
| Number of Residents |
| 145 |
86 |
| Number of RN Hours Per Resident Per Day |
| 0.61 |
0.75 |
| Number of LPN/LVN Hours Per Resident Per Day |
| 0.61 |
0.74 |
| Total Number of Licensed Staff Hours Per Resident Per Day |
| 1.22 |
1.49 |
| Number of CNA Hours Per Resident Per Day |
| 0.03 |
0.07 |
| Number Therapy Hours Per Resident Per Day |
| 0.03 |
0.07 |
| Environmental Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 04/02/2012date Of Correction: 05/31/2012 |
Scope: Fewlevel Of Harm: 4deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 04/29/2010date Of Correction: 06/03/2010 |
| Deficiency #2 |
| Scope: Somelevel Of Harm: 2deficiency: Provide Housekeeping And Maintenance Services.survey Date: 04/02/2012date Of Correction: 05/31/2012 |
Scope: Somelevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 12/10/2009date Of Correction: 01/11/2010 |
| Deficiency #3 |
| Scope: Somelevel Of Harm: 2deficiency: Provide A Safe, Clean, Comfortable And Homelike Environment.survey Date: 04/02/2012date Of Correction: 05/31/2012 |
|
| Deficiency #4 |
| Scope: Somelevel Of Harm: 2deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.survey Date: 01/19/2011date Of Correction: 02/19/2011 |
|
| Deficiency #5 |
| Scope: Somelevel Of Harm: 2deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.survey Date: 09/22/2009date Of Correction: 10/22/2009 |
|
| Mistreatment Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: 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: 04/02/2012date Of Correction: 05/31/2012 |
Scope: Fewlevel Of Harm: 2deficiency: 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: 01/19/2012date Of Correction: 02/10/2012 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 01/19/2011date Of Correction: 02/19/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Keep Each Resident Free From Physical Restraints, Unless Needed For Medical Treatment.survey Date: 01/19/2012date Of Correction: 02/10/2012 |
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: 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: 01/19/2011date Of Correction: 02/19/2011 |
Scope: Fewlevel Of Harm: 2deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.survey Date: 04/29/2010date Of Correction: 06/03/2010 |
| Deficiency #4 |
|
Scope: Fewlevel Of Harm: 2deficiency: 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: 04/29/2010date Of Correction: 06/03/2010 |
| Resident Rights Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.survey Date: 04/02/2012date Of Correction: 05/31/2012 |
Scope: Fewlevel Of Harm: 4deficiency: 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: 12/07/2010date Of Correction: 10/14/2010 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Keep Each Resident's Personal And Medical Records Private And Confidential.survey Date: 01/06/2010date Of Correction: 02/06/2010 |
Scope: Fewlevel Of Harm: 4deficiency: 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: 12/10/2009date Of Correction: 01/11/2010 |
| Deficiency #3 |
|
Scope: Fewlevel Of Harm: 2deficiency: Reasonably Accommodate The Needs And Preferences Of Each Resident.survey Date: 09/21/2009date Of Correction: 10/21/2009 |
| Quality Care Deficiencies |
| Deficiency #1 |
| Scope: Fewlevel Of Harm: 2deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 04/02/2012date Of Correction: 05/31/2012 |
Scope: Fewlevel Of Harm: 4deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 12/07/2010date Of Correction: 10/14/2010 |
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.survey Date: 04/02/2012date Of Correction: 05/31/2012 |
Scope: Fewlevel Of Harm: 2deficiency: Make Sure That Residents With Reduced Range Of Motion Get Proper Treatment And Services To Increase Range Of Motion.survey Date: 12/10/2009date Of Correction: 01/11/2010 |
| Deficiency #3 |
| Scope: Fewlevel Of Harm: 2deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 04/02/2012date Of Correction: 05/31/2012 |
Scope: Fewlevel Of Harm: 2deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.survey Date: 12/10/2009date Of Correction: 01/11/2010 |
| Deficiency #4 |
| Scope: Fewlevel Of Harm: 2deficiency: 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: 01/06/2010date Of Correction: 02/06/2010 |
Scope: Fewlevel Of Harm: 4deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .survey Date: 12/10/2009date Of Correction: 01/11/2010 |
| Deficiency #5 |
| Scope: Fewlevel Of Harm: 2deficiency: 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: 09/22/2009date Of Correction: 10/22/2009 |
Scope: Fewlevel Of Harm: 2deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses.survey Date: 09/21/2009date Of Correction: 10/21/2009 |
| Deficiency #6 |
| Scope: Fewlevel Of Harm: 2deficiency: 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: 04/21/2009date Of Correction: 05/21/2009 |
|
| Resident Assessment Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.survey Date: 04/02/2012date Of Correction: 05/31/2012 |
|
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.survey Date: 01/06/2010date Of Correction: 02/06/2010 |
|
| Administration Deficiencies |
| Deficiency #1 |
| Scope: Somelevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 04/02/2012date Of Correction: 05/31/2012 |
|
| Deficiency #2 |
| Scope: Fewlevel Of Harm: 2deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.survey Date: 04/21/2009date Of Correction: 05/21/2009 |
|
| Pharmacy Service Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.survey Date: 01/19/2012date Of Correction: 02/10/2012 |
| Deficiency #2 |
|
Scope: Fewlevel Of Harm: 2deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.survey Date: 06/03/2010date Of Correction: 06/11/2010 |
| Deficiency #3 |
|
Scope: Fewlevel Of Harm: 2deficiency: Maintain Drug Records And Properly Mark/label Drugs And Other Similar Products According To Accepted Professional Standards.survey Date: 12/10/2009date Of Correction: 01/11/2010 |
| Deficiency #4 |
|
Scope: Somelevel Of Harm: 2deficiency: 1) Make Sure That Each Resident's Drug Regimen Is Free From Unnecessary Drugs; 2) Each Resident's Entire Drug/medication Is Managed And Monitored To Achieve Highest Well Being.survey Date: 12/10/2009date Of Correction: 01/11/2010 |
| Nutrition and Dietary Deficiencies |
| Deficiency #1 |
|
Scope: Fewlevel Of Harm: 2deficiency: Prepare Food That Is Nutritional, Appetizing, Tasty, Attractive, Well-cooked, And At The Right Temperature.survey Date: 09/21/2009date Of Correction: 10/21/2009 |
| Quality Measures Q1 |
| Percent of long-stay residents who received an antipsychotic medication |
| 24.2 % |
11 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 75.2 % |
5.2 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 14.3 % |
13.9 / 15.3 |
| Percent of long-stay high-risk residents with pressure ulcers |
| 4.2 % |
10.3:1 |
| Percent of long-stay residents who lose too much weight |
| 6.3 % |
8.9 / 9.9 |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 39.3 % |
42.9 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 5.1 % |
4.8 % |
| Percent of long-stay residents with a urinary tract infection |
| 1.6 % |
6.3 % |
| Percent of long-stay residents who have depressive symptoms |
| 4 % |
5 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
1.3 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 26 % |
24 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 93.5 % |
96.7 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 91.9 % |
95 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 75.2 |
75.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 3.9 % |
3.8 % |
| Quality Measures Q3 |
| Percent of long-stay residents who received an antipsychotic medication |
| 24.2 % |
9.5 % |
| Percent of long-stay residents whose need for help with daily activities has increased |
| 0.3 % |
3.3 % |
| Percent of long-stay residents who self-report moderate to severe pain |
| 13.1:1 |
18.4 % |
| Percent of long-stay high-risk residents with pressure ulcers |
| 3.2 % |
8.8 % |
| Percent of long-stay residents who lose too much weight |
| 9 % |
8.5 % |
| Percent of long-stay low-risk residents who lose control of their bowels or bladder |
| 39.4 % |
39.8 % |
| Percent of long-stay residents who have had a catheter inserted and left in their bladder |
| 4.5 % |
4.4 % |
| Percent of long-stay residents with a urinary tract infection |
| 1.8 % |
6.9 % |
| Percent of long-stay residents who have depressive symptoms |
| 4.7 % |
7.2 % |
| Percent of long-stay residents who were physically restrained |
| 75.2 % |
1.2 % |
| Percent of long-stay residents experiencing one or more falls with major injury |
| 4.7 % |
2.8 % |
| Percent of short-stay residents who self-report moderate to severe pain |
| 23.2 % |
24.6 % |
| Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine |
| 77.1 % |
81.5 % |
| Percent of short-stay residents with Pressure ulcers that are new or worsened |
| 87.8 % |
83.9 % |
| Percent of short-stay residents who newly received an antipsychotic medication |
| 2.9 % |
10.1:1 |