KINDRED TRANSITIONAL CARE AND REHAB-SAN LUIS (GREEN BAY, WI) Detailed Nursing Home Profile

Quality Measures

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

This Nursing Home:	18.8%
State:	15.6%

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

Here:	8.4%
Wisconsin:	11.2%

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

Here:	7.9%
State:	4.6%

Percent of long-stay residents who lose too much weight

Here:	4.1%
State:	7.2%

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

Here:	65.9%
Wisconsin:	45.0%

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

This Nursing Home:	6.0%
State:	4.7%

Percent of long-stay residents with a urinary tract infection

Here:	3.1%
State:	6.4%

Percent of long-stay residents who have depressive symptoms

This Nursing Home:	4.2%
Wisconsin:	6.9%

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

This Nursing Home:	3.1%
State:	3.4%

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

This Nursing Home:	100.0%
State:	97.6%

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

Here:	100.0%
State:	98.4%

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

Here:	23.3%
Wisconsin:	21.8%

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

This Nursing Home:	3.9%
Wisconsin:	1.6%

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

This Nursing Home:	89.4%
Wisconsin:	92.1%

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

This Nursing Home:	86.8%
State:	92.0%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	16.5%
State:	18.8%

Complaint Deficiency

A separate and independent backup electrical power source
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Automatic sprinkler systems that have been maintained in working order
- 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: 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: Potential for minimal harm
- Scope: Some
Properly working alarms on sprinkler valves
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are free from obstructions and can be used at all times
- Harm: Actual harm
- Scope: Many
Exits that are accessible at all times
- Harm: Minimal harm or potential for 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
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
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
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
Give notice to the resident before a room or roommate change
- 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: Few
Automatic sprinkler systems that have been maintained in working order
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Exits that are accessible at all times
- Harm: Actual harm
- Scope: Few
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
Automatic sprinkler systems that have been maintained in working order
- 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: 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
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
Proper backup exit lighting
- 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
Signs that state that exit doors are to be kept closed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Rooms that can be unlocked from inside without a key
- 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
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
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
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
Have a program that investigates, controls and keeps infection from spreading
- 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
Corridors that are separated from common areas by walls constructed to limit the passage of smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Many
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: Some
Automatic sprinkler systems that have been maintained in working order
- 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: Few
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Proper stairway enclosures and vertical shafts
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Signs that state that exit doors are to be kept closed
- 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
Protected exits that allow the resident to escape the building
- 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 installed electrical wiring and equipment
- 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: 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: Some
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

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

This Nursing Home:	1.010
Wisconsin:	0.887

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

This Nursing Home:	0.510
Wisconsin:	0.546

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.520
Wisconsin:	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

KINDRED TRANSITIONAL CARE AND REHAB-SAN LUIS - GREEN BAY, WI

Quality Measures

Complaint Deficiency

Staff Information

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