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MAYVILLE NUR REHAB CTR

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MAYVILLE NUR REHAB CTR VS
Nursing Homes USA
General
City MAYVILLE   0% Nursing Homes USA have MAYVILLE
State attribute explanation WI   2.5% Nursing Homes USA have WI
Street 305 S CLARK ST  
Zip Code 53050  
Phone 9203870354  
Overall Star Rating
3.11
Health Inspections Star Rating
2.83
Nurse Staffing Star Rating
3.17
Quality Measures Star Rating
3.31
RN Only Star Rating
3.17
Number of Certified Beds
133 
108.94
Total Number of Residents
77 
91.25
Percent of Occupied Beds
58 %
83.65 %
Health Survey Date 7/8/2011  
Fire Survey Date 6/28/2011  
Sprinkler Status Fully Sprinklered  90.2% Nursing Homes USA have Fully Sprinklered
Program Participation Medicare And Medicaid  91.5% Nursing Homes USA have Medicare and Medicaid
Type of Ownership For Profit - Corporation  56.7% Nursing Homes USA have For profit - Corporation
Located Within a Hospital? No  93.6% Nursing Homes USA don't have Located Within a Hospital?
Multi Nursing Home Ownership? Yes  54.9% Nursing Homes USA have Multi Nursing Home Ownership?
Resident and Family Councils RESIDENT   66% Nursing Homes USA have RESIDENT
Continuing Care Retirement Community? No  90.9% Nursing Homes USA don't have Continuing Care Retirement Community?
Quality Indicator Survey? No  68.7% Nursing Homes USA don't have Quality Indicator Survey?
Special Focus Facility? Yes  1% Nursing Homes USA have Special Focus Facility?
Civil Money Penalty Count
58.16
Total Enforcement Actions Count
56.31
# of deficiencies
37 
7.48
Staff Information
Number of Residents
77 
91.38
Number of RN Hours Per Resident Per Day
0.62 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.86 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.48 
1.59
Number of CNA Hours Per Resident Per Day
0.11 
5.49
Number Therapy Hours Per Resident Per Day
0.11 
0.10
Environmental Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #2 Scope: Few
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: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Deficiency #4 Scope: Few
level Of Harm: 3
deficiency: Make Sure That The Nursing Home Area Is Free From Accident Hazards And Risks And Provides Supervision To Prevent Avoidable Accidents.
survey Date: 06/09/2010
date Of Correction: 08/12/2010 
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: 07/08/2011
date Of Correction: 08/10/2011 
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: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 4
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 3
deficiency: 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: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #2 Scope: Few
level Of Harm: 4
deficiency: Make Sure Each Resident Has The Right To Have A Choice Over Activities, Their Schedules And Health Care According To His Or Her Interests, Assessment, And Plan Of Care.
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 4
deficiency: 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: 12/07/2010
date Of Correction: 01/10/2011 
Quality Care Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Develop Policies And Procedures For Influenza And Pneumococcal Immunizations.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 4
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #4 Scope: Few
level Of Harm: 3
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #6 Scope: Some
level Of Harm: 2
deficiency: Have Enough Nurses To Care For Every Resident In A Way That Maximizes The Resident's Well Being.
survey Date: 02/24/2011
date Of Correction: 03/24/2011 
Deficiency #7 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Residents With Reduced Range Of Motion Get Proper Treatment And Services To Increase Range Of Motion.
survey Date: 02/24/2011
date Of Correction: 03/24/2011 
Deficiency #8 Scope: Few
level Of Harm: 4
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Deficiency #9 Scope: Few
level Of Harm: 4
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Deficiency #10 Scope: Few
level Of Harm: 2
deficiency: 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: 06/09/2010
date Of Correction: 07/14/2010 
Deficiency #11 Scope: Few
level Of Harm: 3
deficiency: Make Sure That Each Resident Gets A Nutritional And Well Balanced Diet, Unless It Is Not Possible To Do So.
survey Date: 10/27/2009
date Of Correction: 12/22/2009 
Deficiency #12 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 08/13/2009
date Of Correction: 09/12/2009 
Resident Assessment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Doctors Visit Residents Regularly, As Required.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Develop A Complete Care Plan That Meets All Of A Resident's Needs, With Timetables And Actions That Can Be Measured.
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Doctors See A Resident's Plan Of Care At Every Visit And Make Notes About Progress And Orders In Writing.
survey Date: 12/22/2009
date Of Correction: 01/19/2010 
Administration Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Give Or Get Quality Lab Services/tests In A Timely Manner To Meet The Needs Of Residents.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #3 Scope: Many
level Of Harm: 1
deficiency: Post Nurse Staffing Information/data On A Daily Basis.
survey Date: 02/24/2011
date Of Correction: 03/24/2011 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Deficiency #5 Scope: Some
level Of Harm: 2
deficiency: Employ Qualified Full-time, Part-time Or Consultant Professionals That Must Be Licensed, Certified, Or Registered Staff To Give Needed Services.
survey Date: 12/07/2010
date Of Correction: 01/10/2011 
Deficiency #6 Scope: Few
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: 12/07/2010
date Of Correction: 01/10/2011 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 07/08/2011
date Of Correction: 08/10/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 06/09/2010
date Of Correction: 08/12/2010 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Safely Provide Drugs And Other Similar Products Available, Which Are Needed Every Day And In Emergencies, By A Licensed Pharmacist.
survey Date: 12/22/2009
date Of Correction: 01/19/2010 
Deficiency #4 Scope: Few
level Of Harm: 4
deficiency: Make Sure That Residents Are Safe From Serious Medication Errors.
survey Date: 12/22/2009
date Of Correction: 01/19/2010 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
10.6 %
25.09 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
32.95 %
Percent of long-stay residents who self-report moderate to severe pain
13 %
16.66 %
Percent of long-stay high-risk residents with pressure ulcers
4.8 %
12.58 %
Percent of long-stay residents who lose too much weight
5.7 %
11.83 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
46.2 %
44.54 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder 8.9 / 9.9 % 
Percent of long-stay residents with a urinary tract infection
11.4 %
13.46 %
Percent of long-stay residents who have depressive symptoms
11.4 %
28.38 %
Percent of long-stay residents who were physically restrained
75.2 %
43.68 %
Percent of short-stay residents who self-report moderate to severe pain
27.7 %
25.02 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
86 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
88.2 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
2.4 %
45.90 %
Percent of long-stay residents experiencing one or more falls with major injury
2.9 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication 10.3:1 % 
Percent of long-stay residents whose need for help with daily activities has increased
1.9 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
9 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
3.9 %
9.22 %
Percent of long-stay residents who lose too much weight
8.8 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
49.1 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder 8.9 / 9.9 % 
Percent of long-stay residents with a urinary tract infection
12.2 %
9.58 %
Percent of long-stay residents who have depressive symptoms 7.9:1 % 
Percent of long-stay residents who were physically restrained
75.2 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
2.9 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
20.1 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
88.5 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
91.5 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
19.2 %
17.34 %

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