STRAWBERRY LANE MEDICAL AND REHAB (WISCONSIN RAPIDS, WI) Detailed Nursing Home Profile

Quality Measures

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

Here:	24.5%
Wisconsin:	15.6%

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

Here:	4.2%
State:	11.2%

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

This Nursing Home:	9.8%
State:	4.6%

Percent of long-stay residents who lose too much weight

Here:	5.0%
Wisconsin:	7.2%

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

This Nursing Home:	3.6%
Wisconsin:	4.7%

Percent of long-stay residents with a urinary tract infection

This Nursing Home:	8.1%
State:	6.4%

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

Here:	4.5%
Wisconsin:	3.4%

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

This Nursing Home:	91.0%
State:	97.6%

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

Here:	94.0%
Wisconsin:	98.4%

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

This Nursing Home:	27.3%
State:	21.8%

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

Here:	1.3%
State:	1.6%

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

Here:	82.7%
Wisconsin:	92.1%

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

Here:	81.7%
Wisconsin:	92.0%

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

Here:	1.4%
Wisconsin:	1.8%

Percent of long-stay residents who received an antipsychotic medication

Here:	15.9%
State:	18.8%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.890
State:	0.887

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

This Nursing Home:	0.290
Wisconsin:	0.546

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.180
State:	1.429

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.020
Wisconsin:	0.074

Number Therapy Hours Per Resident Per Day

This Nursing Home:	0.020
Wisconsin:	0.079

Complaint Deficiency

Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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: Few
Restrictions on the use of portable space heaters
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper backup exit lighting
- 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
A two-hour-resistant firewall in common walls
- 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
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper medical gas storage and administration areas
- 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: Few
Exits that are accessible at all times
- 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
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 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
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
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
Employ or obtain outside professional resources providing services in the nursing home that meet professional standards
- Harm: Potential for minimal harm
- Scope: Many
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property
- 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
A two-hour-resistant firewall in common walls
- 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: 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
Rooms that can be unlocked from inside without a key
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Fire-resistant room wall surfaces
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper backup exit lighting
- 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
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
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: Few
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- 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
Provide care by qualified persons according to each resident's written plan of care
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide necessary care and services to maintain the highest well being of each resident
- 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
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: Few
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Potential for minimal harm
- Scope: Many
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs
- Harm: Minimal harm or potential for actual harm
- 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: Few
Make sure services provided by the nursing facility meet professional standards of quality
- 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
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
Have a program that investigates, controls and keeps infection from spreading
- 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
Smoke barrier doors that can resist smoke for at least 20 minutes
- 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
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Properly working alarms on sprinkler valves
- Harm: Potential for minimal harm
- Scope: Many
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
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: Few
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Conduct initial and periodic assessments of each resident's functional capacity
- 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: Some
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: 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: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible
- 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
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
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing
- 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
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- Harm: Minimal harm or potential for actual harm
- Scope: Many

STRAWBERRY LANE MEDICAL AND REHAB - WISCONSIN RAPIDS, WI

Quality Measures

Staff Information

Complaint Deficiency

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