Back

TIVOLI AT DIVINE SAVIOR HEALTHCARE

Details Rankings Comparisons Related
Compare with other Nursing Homes USA
 Compare
TIVOLI AT DIVINE SAVIOR HEALTHCARE VS
Nursing Homes USA
General
Percent of short-stay residents with Pressure ulcers that are new or worsened 75.2 % 
City PORTAGE   0% Nursing Homes USA have PORTAGE
State attribute explanation WI   2.5% Nursing Homes USA have WI
Street 2805 HUNTERS TRAIL  
Zip Code 53901  
Phone 6087454306  
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
83 
108.94
Total Number of Residents
78 
91.25
Percent of Occupied Beds
94 %
83.65 %
Health Survey Date 2/15/2012  
Fire Survey Date 2/8/2012  
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 Non Profit - Church Related  4.4% Nursing Homes USA have Non profit - Church related
Located Within a Hospital? Yes  6.4% Nursing Homes USA 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
56.31
# of deficiencies
28 
7.48
Staff Information
Number of Residents
78 
91.38
Number of RN Hours Per Resident Per Day
1.09 
0.77
Number of LPN/LVN Hours Per Resident Per Day
0.52 
0.84
Total Number of Licensed Staff Hours Per Resident Per Day
1.61 
1.59
Number of CNA Hours Per Resident Per Day
0.07 
5.49
Number Therapy Hours Per Resident Per Day
0.07 
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: 02/15/2012
date Of Correction: 03/15/2012 
Deficiency #2 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: 09/15/2010
date Of Correction: 10/15/2010 
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: 02/08/2010
date Of Correction: 03/08/2010 
Deficiency #4 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: 09/17/2009
date Of Correction: 10/17/2009 
Mistreatment Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Develop Policies That Prevent Mistreatment, Neglect, Or Abuse Of Residents Or Theft Of Resident Property.
survey Date: 02/08/2010
date Of Correction: 03/08/2010 
Deficiency #2 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: 02/08/2010
date Of Correction: 03/08/2010 
Resident Rights Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
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: 06/14/2011
date Of Correction: 07/14/2011 
Deficiency #2 Scope: Few
level Of Harm: 2
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: 09/17/2009
date Of Correction: 10/17/2009 
Quality Care Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: Give Each Resident Enough Fluids To Keep Them Healthy And Prevent Dehydration.
survey Date: 02/15/2012
date Of Correction: 03/15/2012 
Deficiency #2 Scope: Some
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 02/15/2012
date Of Correction: 03/15/2012 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Give Each Resident Enough Fluids To Keep Them Healthy And Prevent Dehydration.
survey Date: 06/14/2011
date Of Correction: 07/14/2011 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Make Sure That Each Resident Gets A Nutritional And Well Balanced Diet, Unless It Is Not Possible To Do So.
survey Date: 06/14/2011
date Of Correction: 07/14/2011 
Deficiency #5 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: 06/14/2011
date Of Correction: 07/14/2011 
Deficiency #6 Scope: Few
level Of Harm: 2
deficiency: Provide Care By Qualified Persons According To Each Resident's Written Plan Of Care.
survey Date: 06/14/2011
date Of Correction: 07/14/2011 
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: 02/08/2010
date Of Correction: 03/08/2010 
Deficiency #8 Scope: Few
level Of Harm: 2
deficiency: Give Residents Proper Treatment To Prevent New Bed (pressure) Sores Or Heal Existing Bed Sores.
survey Date: 09/17/2009
date Of Correction: 10/17/2009 
Resident Assessment Deficiencies
Deficiency #1 Scope: Some
level Of Harm: 2
deficiency: Make Sure Each Resident Receives An Accurate Assessment By A Qualified Health Professional.
survey Date: 02/15/2012
date Of Correction: 03/15/2012 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.
survey Date: 06/14/2011
date Of Correction: 07/14/2011 
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: 01/06/2011
date Of Correction: 02/10/2011 
Deficiency #4 Scope: Some
level Of Harm: 2
deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.
survey Date: 09/15/2010
date Of Correction: 10/15/2010 
Deficiency #5 Scope: Few
level Of Harm: 2
deficiency: Conduct Initial And Periodic Assessments Of Each Resident's Functional Capacity.
survey Date: 02/08/2010
date Of Correction: 03/08/2010 
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: 02/15/2012
date Of Correction: 03/15/2012 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 06/14/2011
date Of Correction: 07/14/2011 
Deficiency #3 Scope: Few
level Of Harm: 2
deficiency: Keep Accurate, Complete And Organized Clinical Records On Each Resident That Meet Professional Standards.
survey Date: 02/08/2010
date Of Correction: 03/08/2010 
Deficiency #4 Scope: Few
level Of Harm: 2
deficiency: Quickly Tell The Resident's Doctor The Results Of Lab Tests.
survey Date: 02/08/2010
date Of Correction: 03/08/2010 
Pharmacy Service Deficiencies
Deficiency #1 Scope: Few
level Of Harm: 2
deficiency: 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: 02/15/2012
date Of Correction: 03/15/2012 
Deficiency #2 Scope: Few
level Of Harm: 2
deficiency: 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: 06/14/2011
date Of Correction: 07/14/2011 
Nutrition and Dietary Deficiencies
Deficiency #1 Scope: Many
level Of Harm: 2
deficiency: Store, Cook, And Serve Food In A Safe And Clean Way.
survey Date: 02/15/2012
date Of Correction: 03/15/2012 
Quality Measures Q1
Percent of long-stay residents who received an antipsychotic medication
11.1 %
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 15.9:1 % 
Percent of long-stay high-risk residents with pressure ulcers
12.5 %
12.58 %
Percent of long-stay residents who lose too much weight
27.7 %
11.83 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
5.2 %
15.63 %
Percent of long-stay residents with a urinary tract infection
6.2 %
13.46 %
Percent of long-stay residents who have depressive symptoms
75.2 %
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 22.4:1 % 
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
97.9 %
84.64 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
96.9 %
83.94 %
Percent of short-stay residents who newly received an antipsychotic medication
75.2 %
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
9 %
25.39 %
Percent of long-stay residents whose need for help with daily activities has increased
0.7 %
23.70 %
Percent of long-stay residents who self-report moderate to severe pain
12.5 %
14.10 %
Percent of long-stay high-risk residents with pressure ulcers
9.6 %
9.22 %
Percent of long-stay residents who lose too much weight
28.5 %
8.50 %
Percent of long-stay low-risk residents who lose control of their bowels or bladder
44.4 %
43.38 %
Percent of long-stay residents who have had a catheter inserted and left in their bladder
5 %
10.65 %
Percent of long-stay residents with a urinary tract infection
8.3 %
9.58 %
Percent of long-stay residents who have depressive symptoms
1 %
19.86 %
Percent of long-stay residents who were physically restrained
0.5 - 2.0 %
38.53 %
Percent of long-stay residents experiencing one or more falls with major injury
2 %
10.73 %
Percent of short-stay residents who self-report moderate to severe pain 21.2:1 % 
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
97.1 %
81.44 %
Percent of short-stay residents with Pressure ulcers that are new or worsened
94 %
74.75 %
Percent of short-stay residents who newly received an antipsychotic medication
0.5 - 2.0 %
17.34 %

saved