CEDAR SPRINGS HLTH REHAB CTR - CEDARBURG, WI

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Addresss:

N27 W5707 LINCOLN BLVD
CEDARBURG, WI, 53012

Phone (make sure to verify first before calling): (262) 376-7676

Number of Certified Beds: 78
Total Number of Residents: 54
Percent of Occupied Beds: 69%
Sprinkler Status: Fully Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: For profit - Corporation
Located Within a Hospital?: No
Multi Nursing Home Ownership?: Yes
Resident and Family Councils: Resident
Continuing Care Retirement Community?: No
Quality Indicator Survey?: No
Special Focus Facility?: No
Type: Skilled Nursing Facilities

Overall Star Rating: 4 Stars
Health Inspections Star Rating: 3 Stars
Nurse Staffing Star Rating: 4 Stars
Quality Measures Star Rating: 4 Stars
RN Only Star Rating: 5 Stars

Employment Full-Time Equivalent

Administrative Staff - Full Time: 4.64

Certified Nurse Aides - Full Time: 10.09

Certified Nurse Aides - Part Time: 13.34

Food Service Personnel - Full Time: 3.54

Food Service Personnel - Part Time: 4.74

Licensed Practical/ Vocational Nurses - Full Time: 3.19

Licensed Practical/ Vocational Nurses - Part Time: 4.09

Medical Directors - Under Contract: 0.11

Nurses With Administrative Duties - Full Time: 3.43

Persons Not Included In Any Other Categories - Full Time: 2.79

Registered Nurses - Full Time: 3.47

Rn Director Of Nursing - Full Time: 1.14

Social Workers - Full Time: 1.76

Activities Professionals - Full Time: 1.04

Occupational Therapists - Part Time: 1.31

Physical Therapists - Part Time: 0.90

Persons Not Included In Any Other Categories - Under Contract: 1.04

Housekeeping Personnel - Under Contract: 3.69

Other Physicians - Under Contract: 0.06

Dietitians - Full Time: 1.14

Sppech Pathologists - Full Time: 2.60

Registered Nurses - Part Time: 2.17

Occupational Therapists - Full Time: 4.70

Physical Therapists - Full Time: 4.23

Occupational Therapy Assistants - Full Time: 3.36

Physical Therapy Aide - Full Time: 2.17

Occupational Therapy Assistants - Part Time: 0.11

Speech Pathologists - Part Time: 0.51

Medication Aides/ Technicians - Part Time: 0.11

Number Of Beds

Total: 78

Total Certified: 78

Provided Services

Activities Services Are Provided Onsite To Residents

Clinical Laboratory Services Are Provided Onsite To Residents

Dental Services Are Provided Onsite To Residents

Diagnostic Xray Services Are Provided Onsite To Residents

Dietary Services Are Provided Onsite To Non Residents

Dietary Services Are Provided Onsite To Residents

Housekeeping Services Are Provided Onsite To Residents

Mental Health Services Are Provided Onsite To Residents

Nursing Services Are Provided Onsite To Residents

Occupational Therapy Services Are Provided Offsite To Residents

Occupational Therapy Services Are Provided Onsite To Non Residents

Occupational Therapy Services Are Provided Onsite To Residents

Pharmacy Services Are Provided Onsite To Residents

Physical Therapy Services Are Provided Offsite To Residents

Physical Therapy Services Are Provided Onsite To Non Residents

Physical Therapy Services Are Provided Onsite To Residents

Physician Extender Services Are Provided Onsite To Residents

Physician Services Are Provided Onsite To Residents

Podiatry Services Are Provided Onsite To Residents

Social Work Services Are Provided Onsite To Residents

Speech/Language Pathology Services Are Provided Offsite To Residents

Speech/Language Pathology Services Are Provided Onsite To Non Residents

Speech/Language Pathology Services Are Provided Onsite To Residents

Quality Measures

Percent of long-stay residents who lose too much weight

Here:	10.0%
State:	7.2%

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

Here:	6.5%
State:	4.7%

Percent of long-stay residents with a urinary tract infection

Here:	23.3%
Wisconsin:	6.4%

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

Here:	3.3%
State:	3.4%

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

This Nursing Home:	100.0%
Wisconsin:	97.6%

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

Here:	100.0%
Wisconsin:	98.4%

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

This Nursing Home:	13.6%
State:	21.8%

Percent of short-stay residents with Pressure ulcers that are new or worsened

Here:	1.6%
Wisconsin:	1.6%

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

This Nursing Home:	90.6%
State:	92.1%

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

This Nursing Home:	93.7%
Wisconsin:	92.0%

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

Here:	2.9%
Wisconsin:	1.8%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	16.7%
Wisconsin:	18.8%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	1.390
Wisconsin:	0.887

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

This Nursing Home:	0.420
Wisconsin:	0.546

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.810
Wisconsin:	1.429

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.190
State:	0.074

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.190
Wisconsin:	0.079

Complaint Deficiency

Post nurse staffing information/data on a daily basis
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Encode and automate the resident's assessment data
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- 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: Few
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Smoke barrier doors that can resist smoke for at least 20 minutes
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Some
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Properly sized and located linen or trash receptacles
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Other fire safety features required by fire safety codes
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Weekly inspections and monthly testing of generators
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Allow residents to easily view the results of the nursing home's most recent survey
- Harm: Potential for minimal harm
- Scope: Many
Dispose of garbage and refuse properly
- Harm: Potential for minimal harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly located and lighted Exit signs
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are free from obstructions and can be used at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed electrical wiring and equipment
- 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: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident's personal and medical records private and confidential
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Allow the resident the right to participate in the planning or revision of the resident's care plan
- 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
Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene
- 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: Immediate jeopardy to resident health or safety
- 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: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- 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: Few

CEDAR SPRINGS HLTH REHAB CTR - CEDARBURG, WI

Quality Measures

Staff Information

Complaint Deficiency

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