GOLDEN LIVINGCENTER-COLONIAL MNR (GLENDALE, WI) Detailed Nursing Home Profile

Quality Measures

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

Here:	26.4%
State:	15.6%

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

Here:	5.2%
State:	11.2%

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

Here:	10.9%
Wisconsin:	4.6%

Percent of long-stay residents who lose too much weight

This Nursing Home:	5.5%
State:	7.2%

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

This Nursing Home:	31.4%
Wisconsin:	45.0%

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

This Nursing Home:	0.8%
Wisconsin:	4.7%

Percent of long-stay residents with a urinary tract infection

Here:	4.4%
State:	6.4%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	1.2%
Wisconsin:	6.9%

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

This Nursing Home:	4.4%
State:	3.4%

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

Here:	78.0%
State:	97.6%

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

This Nursing Home:	82.4%
Wisconsin:	98.4%

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

This Nursing Home:	12.1%
State:	21.8%

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

Here:	13.2%
State:	92.1%

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

Here:	20.2%
Wisconsin:	92.0%

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

This Nursing Home:	1.2%
State:	1.8%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	9.3%
State:	18.8%

Complaint Deficiency

Did not have a written emergency evacuation plan
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Employ or obtain outside professional resources providing services in the nursing home that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A two-hour-resistant firewall in common walls
- 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: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
Exits that are accessible at all times
- Harm: Actual harm
- Scope: Few
Signs that state that exit doors are to be kept closed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- 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
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- 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: Some
Conduct initial and periodic assessments of each resident's functional capacity
- 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: Few
Provide housekeeping and maintenance services
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Hire sufficient dietary support personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide doctors orders for the resident's immediate care, at the time the resident was admitted
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
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
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: Some
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Post nurse staffing information/data on a daily basis
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide housekeeping and maintenance services
- Harm: Potential for minimal harm
- Scope: Some
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
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure each resident receives an accurate assessment by a qualified health professional
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide necessary care and services to maintain the highest well being of each resident
- 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
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
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Actual harm
- Scope: Few
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
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Operate and provide services according to Federal, State, and local laws and professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews
- Harm: Minimal harm or potential for actual harm
- Scope: Many
A two-hour-resistant firewall in common walls
- 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: Few
Construction that can resist fire for one hour or an approved fire extinguishing system
- 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
Did not have a written emergency evacuation plan
- Harm: Potential for minimal harm
- Scope: Many
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: Some
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Try to resolve each resident's complaints quickly
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Reasonably accommodate the needs and preferences of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide medically-related social services to help each resident achieve the highest possible quality of life
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide a safe, clean, comfortable and homelike environment
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Immediate jeopardy to resident health or safety
- 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: Few
Make sure that residents are safe from serious medication errors
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Have enough nurses to care for every resident in a way that maximizes the resident's well being
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Keep accurate, complete and organized clinical records on each resident that meet professional standards
- 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
Smoke barrier doors that can resist smoke for at least 20 minutes
- 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
Protected exits that allow the resident to escape the building
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Corridors or aisles that are unobstructed and are at least 8 feet in width
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Rooms that can be unlocked from inside without a key
- 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
A fire alarm system that can be heard throughout the facility
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions
- 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: Some
Proper medical gas storage and administration areas
- 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
Properly installed electrical wiring and equipment
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly installed hallway dispensers for alcohol-based hand rub
- 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
Smoke barrier doors that can resist smoke for at least 20 minutes
- 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
Corridors or aisles that are unobstructed and are at least 8 feet in width
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Rooms that can be unlocked from inside without a key
- 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: Some
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly constructed linen or trash chutes
- 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
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
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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 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

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.720
Wisconsin:	0.887

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

Here:	0.920
State:	0.546

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.640
State:	1.429

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.100
State:	0.074

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.100
State:	0.079

GOLDEN LIVINGCENTER-COLONIAL MNR - GLENDALE, WI

Quality Measures

Complaint Deficiency

Staff Information

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