MEMORIAL NURSING AND REHAB CENTER (MEDFORD, WI) Detailed Nursing Home Profile

Quality Measures

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

Here:	14.7%
Wisconsin:	15.6%

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

This Nursing Home:	36.3%
State:	11.2%

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

This Nursing Home:	3.8%
Wisconsin:	4.6%

Percent of long-stay residents who lose too much weight

This Nursing Home:	3.7%
Wisconsin:	7.2%

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

This Nursing Home:	43.8%
Wisconsin:	45.0%

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

Here:	7.2%
Wisconsin:	4.7%

Percent of long-stay residents with a urinary tract infection

Here:	13.4%
State:	6.4%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	2.4%
State:	6.9%

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

Here:	2.4%
State:	3.4%

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

Here:	83.3%
Wisconsin:	97.6%

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

This Nursing Home:	98.8%
Wisconsin:	98.4%

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

Here:	36.8%
State:	21.8%

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

Here:	69.4%
State:	92.1%

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

Here:	93.8%
State:	92.0%

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

Here:	4.9%
State:	1.8%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	16.2%
State:	18.8%

Use of Medical Imaging

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.

This Nursing Home:	5.000%
State:	8.007%

Outpatient CT scans of the abdomen that were combination (double) scans.

Here:	0.012%
State:	0.080%

Outpatients who got cardiac imaging stress tests before low-risk outpatient surgery

This Nursing Home:	8.200%
State:	5.714%

Complaint Deficiency

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
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Approved construction type or materials
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Minimal harm or potential for actual harm
- Scope: Some
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: Few
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
Keep each resident's personal and medical records private and confidential
- 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
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 services provided by the nursing facility meet professional standards of quality
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients
- Harm: Potential for minimal 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
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 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 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: Some
Exits that are accessible at all times
- 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
Keep each resident's personal and medical records private and confidential
- 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
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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
Weekly inspections and monthly testing of generators
- Harm: Potential for minimal harm
- Scope: Many

Process of Care

Heart Attack

Average number of minutes before outpatients with chest pain or possible heart attack got an ECG

This Nursing Home:	6
Wisconsin:	7

Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival

This Nursing Home:	96.0%
Wisconsin:	97.9%

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)

Here:	100.0%
Wisconsin:	98.3%

Percent of Patients Given Discharge Instructions

This Nursing Home:	92.0%
Wisconsin:	91.1%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

This Nursing Home:	97.0%
Wisconsin:	97.9%

Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics

This Nursing Home:	100.0%
State:	97.6%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	100.0%
Wisconsin:	97.1%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

This Nursing Home:	97.0%
State:	95.6%

Percent of Patients Assessed and Given Influenza Vaccination

This Nursing Home:	40.0%
Wisconsin:	93.4%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	73.0%
State:	96.3%

Surgery

Percent of Surgery Patients given an antibiotic at the right time (within one hour before surgery) to help prevent infection

This Nursing Home:	91.0%
State:	97.9%

Percent of Surgery Patients whose preventive antibiotics were stopped at the right time (within 24 hours after surgery)

Here:	98.0%
Wisconsin:	97.5%

Percent of Surgery Patients who were given the right kind of antibiotic to help prevent infection

Here:	98.0%
State:	99.0%

Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot

This Nursing Home:	100.0%
Wisconsin:	97.0%

Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries

Here:	100.0%
State:	97.7%

Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method

Here:	100.0%
Wisconsin:	99.9%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal

Here:	100.0%
Wisconsin:	99.6%

Outcome of Care

30-Day Mortality Rates from Heart Failure

This Nursing Home:	10.5%
State:	11.7%

30-Day Mortality Rates from Pneumonia

This Nursing Home:	11.4%
Wisconsin:	11.9%

30-Day Readmission Rates from Heart Failure

Here:	22.7%
State:	23.7%

30-Day Readmission Rates from Pneumonia

Here:	17.1%
State:	18.1%

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: Between 100 and 299
Survey Response Rate: 44%

How often did nurses communicate well with patients?

Sometimes or never

Here:	2%
State:	3%

Usually

Here:	15%
Wisconsin:	17%

Always

Here:	83%
Wisconsin:	80%

How often did doctors communicate well with patients?

Sometimes or never

Here:	1%
Wisconsin:	3%

Usually

Here:	15%
State:	15%

Always

This Nursing Home:	84%
State:	82%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Nursing Home:	3%
State:	6%

Usually

This Nursing Home:	23%
State:	24%

Always

Here:	74%
State:	70%

How often was patients' pain well controlled?

Sometimes or never

Here:	8%
Wisconsin:	5%

Usually

Here:	24%
State:	24%

Always

This Nursing Home:	68%
Wisconsin:	71%

How often did staff explain about medicines before giving them to patients?

Sometimes or never

Here:	11%
Wisconsin:	15%

Usually

Here:	18%
State:	18%

Always

Here:	71%
Wisconsin:	67%

How often were the patients' rooms and bathrooms kept clean?

Sometimes or never

This Nursing Home:	4%
State:	5%

Usually

Here:	15%
State:	17%

Always

Here:	81%
Wisconsin:	78%

How often was the area around patients' rooms kept quiet at night?

Sometimes or never

This Nursing Home:	5%
Wisconsin:	8%

Usually

Here:	30%
State:	30%

Always

This Nursing Home:	65%
State:	62%

Were patients given information about what to do during their recovery at home?

Yes

This Nursing Home:	89%
State:	87%

Here:	11%
Wisconsin:	13%

How do patients rate the hospital overall on a scale from 0 (lowest) to 10 (highest)?

6 or lower

This Nursing Home:	4%
State:	6%

7 or 8

This Nursing Home:	19%
State:	21%

9 or 10

Here:	77%
State:	73%

Would patients recommend the hospital to friends and family?

This Nursing Home:	4%
State:	3%

Yes, probably

Here:	25%
State:	24%

Yes, definitely

Here:	71%
Wisconsin:	73%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	0.820
State:	0.887

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

This Nursing Home:	0.260
Wisconsin:	0.546

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.080
State:	1.429

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

Here:	0.040
State:	0.074

Number Therapy Hours Per Resident Per Day

Here:	0.040
State:	0.079

MEMORIAL NURSING AND REHAB CENTER - MEDFORD, WI

Quality Measures

Use of Medical Imaging

Complaint Deficiency

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Hospital Consumer Assessment of Healthcare Providers

Staff Information

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