BETHANY ST JOSEPH CARE CTR (LA CROSSE, WI) Detailed Nursing Home Profile

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased

Here:	18.4%
Wisconsin:	15.6%

Percent of long-stay residents who self-report moderate to severe pain

Here:	22.3%
Wisconsin:	11.2%

Percent of long-stay high-risk residents with pressure ulcers

This Nursing Home:	7.1%
State:	4.6%

Percent of long-stay residents who lose too much weight

Here:	10.9%
State:	7.2%

Percent of long-stay low-risk residents who lose control of their bowels or bladder

This Nursing Home:	54.3%
Wisconsin:	45.0%

Percent of long-stay residents who have had a catheter inserted and left in their bladder

Here:	7.1%
State:	4.7%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	4.2%
Wisconsin:	6.4%

Percent of long-stay residents who have depressive symptoms

Here:	31.6%
State:	6.9%

Percent of long-stay residents who were physically restrained

This Nursing Home:	0.8%
State:	0.9%

Percent of long-stay residents experiencing one or more falls with major injury

Here:	2.5%
Wisconsin:	3.4%

Percent of long-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	99.2%
State:	97.6%

Percent of long-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	98.3%
Wisconsin:	98.4%

Percent of short-stay residents who self-report moderate to severe pain

This Nursing Home:	25.3%
State:	21.8%

Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine

Here:	81.4%
State:	92.1%

Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine

This Nursing Home:	87.1%
State:	92.0%

Percent of short-stay residents who newly received an antipsychotic medication

This Nursing Home:	6.7%
Wisconsin:	1.8%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	23.5%
State:	18.8%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.860
Wisconsin:	0.887

Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day

Here:	0.380
State:	0.546

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.250
State:	1.429

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.060
State:	0.074

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.060
State:	0.079

Complaint Deficiency

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Portable fire extinguishers
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Other fire safety features required by fire safety codes
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Determine if it is safe for the resident to self-administer drugs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Potential for minimal harm
- Scope: Some
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
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Determine if it is safe for the resident to self-administer drugs
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Record of quarterly fire drills for each shift under varying conditions
- Harm: Potential for minimal harm
- Scope: Many
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Record of quarterly fire drills for each shift under varying conditions
- Harm: Potential for minimal harm
- Scope: Many
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Potential for minimal harm
- Scope: Many
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure each resident receives an accurate assessment by a qualified health professional
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some

BETHANY ST JOSEPH CARE CTR - LA CROSSE, WI

Quality Measures

Staff Information

Complaint Deficiency

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