VIRGINIA HEALTH AND REHAB CTR (WAUKESHA, WI) Detailed Nursing Home Profile

Quality Measures

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

Here:	23.0%
Wisconsin:	15.6%

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

Here:	3.1%
State:	11.2%

Percent of long-stay residents who lose too much weight

This Nursing Home:	8.6%
Wisconsin:	7.2%

Percent of long-stay residents who have depressive symptoms

Here:	1.2%
State:	6.9%

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

Here:	7.1%
Wisconsin:	3.4%

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

This Nursing Home:	97.6%
Wisconsin:	97.6%

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

Here:	97.6%
Wisconsin:	98.4%

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

Here:	9.1%
State:	21.8%

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

Here:	1.7%
Wisconsin:	1.6%

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

Here:	86.4%
Wisconsin:	92.1%

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

Here:	78.7%
State:	92.0%

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

Here:	2.5%
Wisconsin:	1.8%

Percent of long-stay residents who received an antipsychotic medication

Here:	20.7%
State:	18.8%

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

This Nursing Home:	0.410
Wisconsin:	0.546

Total Number of Licensed Staff Hours Per Resident Per Day

This Nursing Home:	1.130
State:	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
Wisconsin:	0.079

Complaint Deficiency

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
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
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
Weekly inspections and monthly testing of generators
- 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
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Let the resident refuse treatment or refuse to take part in an experiment and formulate advance directives
- Harm: Minimal harm or potential for actual harm
- Scope: Few
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
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
Make sure each resident receives an accurate assessment by a qualified health professional
- 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
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 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
Have a program that investigates, controls and keeps infection from spreading
- 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
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
Emergency lighting that can last at least 1 1/2 hours
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Properly protected cooking facilities
- 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
Other fire safety features required by fire safety codes
- 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: Few
Exits that are accessible at all times
- 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
Properly located and lighted Exit signs
- 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
Posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed
- 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
Weekly inspections and monthly testing of generators
- 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
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: Some
Signs that state that exit doors are to be kept closed
- 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: Few
A fire alarm system that can be heard throughout the facility
- 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: 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: Many
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: Some
Store, cook, and serve food in a safe and clean way
- 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

VIRGINIA HEALTH AND REHAB CTR - WAUKESHA, WI

Quality Measures

Staff Information

Complaint Deficiency

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