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ST FRANCIS IN THE PARK HLTH REHAB

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ST FRANCIS IN THE PARK HLTH REHAB VS
Nursing Homes USA
General
City SUPERIOR   0% Nursing Homes USA have SUPERIOR
State attribute explanation WI   2.5% Nursing Homes USA have WI
Street 1800 NEW YORK AVE  
Zip Code 54880  
Phone 7153945591  
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
168 
108.94
Total Number of Residents
52 
91.25
Percent of Occupied Beds
31 %
83.65 %
Health Survey Date 9/29/2011  
Fire Survey Date 10/11/2011  
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? No  45.1% Nursing Homes USA don't 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? No  99% Nursing Homes USA don't have Special Focus Facility?
Civil Money Penalty Count
58.16
Total Enforcement Actions Count
13 
56.31
# of deficiencies
27 
7.48
Staff Information
Number of Residents
52 
91.38
Number of RN Hours Per Resident Per Day
1.2 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.35 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.55 
1.59
Number of CNA Hours Per Resident Per Day
0.01 
5.49
Number Therapy Hours Per Resident Per Day
0.01 
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: 12/03/2010
date Of Correction: 12/17/2010 
Deficiency #2 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: 09/21/2010
date Of Correction: 12/17/2010 
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: 07/08/2010
date Of Correction: 08/12/2010 
Deficiency #4 Scope: Some
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: 05/04/2010
date Of Correction: 05/14/2010 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Have A Program That Investigates, Controls And Keeps Infection From Spreading.
survey Date: 08/11/2009
date Of Correction: 12/18/2009 
Deficiency #6 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: 08/11/2009
date Of Correction: 11/17/2009 
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: 11/17/2009
date Of Correction: 12/18/2009 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 04/10/2009
date Of Correction: 05/08/2009 
Deficiency #3 Scope: Few
level Of Harm: 3
deficiency: Write And Use Policies That Forbid Mistreatment, Neglect And Abuse Of Residents And Theft Of Residents' Property.
survey Date: 04/10/2009
date Of Correction: 05/08/2009 
Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Determine If It Is Safe For The Resident To Self-administer Drugs.
survey Date: 05/04/2010
date Of Correction: 05/14/2010 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Provide Care For Residents In A Way That Keeps Or Builds Each Resident's Dignity And Respect Of Individuality.
survey Date: 08/11/2009
date Of Correction: 12/18/2009 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Let The Resident Refuse Treatment Or Refuse To Take Part In An Experiment And Formulate Advance Directives.
survey Date: 04/10/2009
date Of Correction: 05/08/2009 
Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Properly Care For Residents Needing Special Services, Including: Injections, Colostomy, Ureostomy, Ileostomy, Tracheostomy Care, Tracheal Suctioning, Respiratory Care, Foot Care, And Prostheses.
survey Date: 12/03/2010
date Of Correction: 12/17/2010 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 12/03/2010
date Of Correction: 12/17/2010 
Deficiency #3 Scope: Some
level Of Harm: 2
deficiency: Make Sure Services Provided By The Nursing Facility Meet Professional Standards Of Quality.
survey Date: 08/12/2010
date Of Correction: 08/25/2010 
Deficiency #4 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: 07/08/2010
date Of Correction: 08/12/2010 
Deficiency #5 Scope: Some
level Of Harm: 4
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 09/03/2009
date Of Correction: 12/18/2009 
Deficiency #6 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: 08/11/2009
date Of Correction: 11/17/2009 
Deficiency #7 Scope: Few
level Of Harm: 3
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 08/11/2009
date Of Correction: 11/17/2009 
Deficiency #8 Scope: Few
level Of Harm: 2
deficiency: Assist Those Residents Who Need Total Help With Eating/drinking, Grooming And Personal And Oral Hygiene.
survey Date: 08/11/2009
date Of Correction: 12/18/2009 
Deficiency #9 Scope: Few
level Of Harm: 2
deficiency: Provide Necessary Care And Services To Maintain The Highest Well Being Of Each Resident .
survey Date: 08/11/2009
date Of Correction: 12/18/2009 
Deficiency #10 Scope: Few
level Of Harm: 2
deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.
survey Date: 08/11/2009
date Of Correction: 12/18/2009 
Resident Assessment Deficiencies
Deficiency #1 Scope: Some
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: 09/03/2009
date Of Correction: 11/17/2009 
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: 12/03/2010
date Of Correction: 12/17/2010 
Deficiency #2 Scope: Few
level Of Harm: 4
deficiency: Give Or Get Quality Lab Services/tests In A Timely Manner To Meet The Needs Of Residents.
survey Date: 09/03/2009
date Of Correction: 11/17/2009 
Pharmacy Service Deficiencies
Deficiency #1 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: 08/11/2009
date Of Correction: 12/18/2009 
Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Prepare Food That Is Nutritional, Appetizing, Tasty, Attractive, Well-cooked, And At The Right Temperature.
survey Date: 08/11/2009
date Of Correction: 12/18/2009 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
27.7 %
25.09 %
Percent of long-stay residents who self-report moderate to severe pain
11.7 %
16.66 %
Percent of long-stay high-risk residents with pressure ulcers
8.8 %
12.58 %
Percent of long-stay residents who lose too much weight
12 %
11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
2.4 %
15.63 %
Percent of long-stay residents with a urinary tract infection
4 %
13.46 %
Percent of long-stay residents who have depressive symptoms
4.2 %
28.38 %
Percent of long-stay residents who were physically restrained
75.2 %
43.68 %
Percent of short-stay residents who newly received an antipsychotic medication
45.90
Percent of long-stay residents experiencing one or more falls with major injury
2 %
15.52 %
Quality Measures Q3
Percent of long-stay residents who received an antipsychotic medication
27.3 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
75.2 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
10.5 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
4 %
9.22 %
Percent of long-stay residents who lose too much weight
10.5 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
40.7 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
4.4 %
10.65 %
Percent of long-stay residents with a urinary tract infection
3.9 %
9.58 %
Percent of long-stay residents who have depressive symptoms
2.7 %
19.86 %
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
24.8 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain
42.9 %
24.76 %
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
94.1 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
94.7 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
75.2 %
17.34 %

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