LAKEWOOD HEALTH SYSTEM (STAPLES, MN) Detailed Nursing Home Profile

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: 300 or more
Survey Response Rate: 36%

How often did nurses communicate well with patients?

Sometimes or never

Here:	3%
State:	3%

Usually

This Nursing Home:	13%
State:	18%

Always

This Nursing Home:	84%
Minnesota:	79%

How often did doctors communicate well with patients?

Sometimes or never

Here:	2%
State:	3%

Usually

Here:	11%
State:	14%

Always

This Nursing Home:	87%
Minnesota:	83%

How often did patients receive help quickly from hospital staff?

Sometimes or never

Here:	4%
State:	6%

Usually

Here:	18%
Minnesota:	22%

Always

This Nursing Home:	78%
State:	72%

How often was patients' pain well controlled?

Sometimes or never

Here:	4%
Minnesota:	5%

Usually

This Nursing Home:	21%
State:	25%

Always

Here:	75%
State:	70%

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

Sometimes or never

Here:	14%
Minnesota:	16%

Usually

This Nursing Home:	16%
State:	20%

Always

Here:	70%
State:	64%

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

Sometimes or never

This Nursing Home:	4%
State:	6%

Usually

Here:	16%
State:	18%

Always

This Nursing Home:	80%
Minnesota:	76%

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

Sometimes or never

This Nursing Home:	5%
State:	7%

Usually

Here:	22%
Minnesota:	30%

Always

This Nursing Home:	73%
Minnesota:	63%

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

Yes

This Nursing Home:	89%
Minnesota:	86%

This Nursing Home:	11%
State:	14%

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

6 or lower

Here:	5%
Minnesota:	6%

7 or 8

This Nursing Home:	15%
State:	22%

9 or 10

Here:	80%
Minnesota:	72%

Would patients recommend the hospital to friends and family?

This Nursing Home:	2%
State:	3%

Yes, probably

This Nursing Home:	14%
Minnesota:	24%

Yes, definitely

Here:	84%
State:	73%

Quality Measures

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

This Nursing Home:	14.3%
Minnesota:	15.5%

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

Here:	16.5%
State:	12.5%

Percent of long-stay residents who lose too much weight

This Nursing Home:	4.8%
Minnesota:	7.6%

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

Here:	7.7%
State:	4.1%

Percent of long-stay residents with a urinary tract infection

Here:	4.8%
State:	5.2%

Percent of long-stay residents who have depressive symptoms

Here:	7.1%
State:	7.4%

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

Here:	5.7%
Minnesota:	3.9%

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

Here:	100.0%
Minnesota:	97.0%

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

Here:	100.0%
State:	96.8%

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

This Nursing Home:	28.6%
Minnesota:	26.2%

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

This Nursing Home:	2.0%
State:	1.3%

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

This Nursing Home:	100.0%
Minnesota:	87.6%

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

Here:	94.0%
State:	86.3%

Percent of long-stay residents who received an antipsychotic medication

This Nursing Home:	23.9%
Minnesota:	17.4%

Staff Information

Number of Registered Nurses Hours Per Resident Per Day

Here:	0.690
State:	0.794

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

This Nursing Home:	1.080
State:	0.750

Total Number of Licensed Staff Hours Per Resident Per Day

Here:	1.780
State:	1.543

Number of ,Certified Nurse Assistant Hours Per Resident Per Day

This Nursing Home:	0.030
State:	0.078

Number Therapy Hours Per Resident Per Day

Here:	0.030
State:	0.087

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: Many
An approved automatic sprinkler system connected to the fire alarm system
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Other fire safety features required by fire safety codes
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Develop policies that prevent mistreatment, neglect, or abuse of residents or theft of resident property
- Harm: Potential for minimal harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Corridor and hallway doors that block smoke
- 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
Weekly inspections and monthly testing of generators
- Harm: Potential for minimal harm
- Scope: Many
Reasonably accommodate the needs and preferences of each resident
- 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
Provide necessary care and services to maintain the highest well being of each resident
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Post nurse staffing information/data on a daily basis
- Harm: Potential for minimal harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Fire-resistant interior walls
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Corridor and hallway doors that block smoke
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Proper stairway enclosures and vertical shafts
- Harm: Potential for minimal harm
- Scope: Many
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: Many
Record of quarterly fire drills for each shift under varying conditions
- Harm: Potential for minimal harm
- Scope: Many
Properly maintained smoke detectors
- 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
Automatic sprinkler systems that have been maintained in working order
- Harm: Potential for minimal 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: Many
Proper medical gas storage and administration areas
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Fire-resistant Interior walls
- 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
Provide necessary care and services to maintain the highest well being of each resident
- 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

Process of Care

Heart Attack

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

Here:	10
Minnesota:	7

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

This Nursing Home:	100.0%
State:	96.6%

Heart Failure

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

Here:	58.0%
State:	97.5%

Percent of Patients Given Discharge Instructions

This Nursing Home:	80.0%
State:	88.6%

Pneumonia

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

Here:	92.0%
State:	97.1%

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

Here:	92.0%
Minnesota:	96.1%

Percent of Patients Given Smoking Cessation Advice/Counseling

Here:	100.0%
Minnesota:	96.0%

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

This Nursing Home:	88.0%
Minnesota:	92.8%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	54.0%
Minnesota:	93.0%

Percent of Patients Assessed and Given Pneumococcal Vaccination

Here:	68.0%
Minnesota:	94.9%

Surgery

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

Here:	91.0%
Minnesota:	97.4%

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

This Nursing Home:	92.0%
State:	97.6%

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

This Nursing Home:	94.0%
State:	97.9%

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

Here:	94.0%
Minnesota:	96.7%

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

Here:	95.0%
Minnesota:	97.4%

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

This Nursing Home:	100.0%
State:	99.8%

Surgery patients who were taking heart drugs called beta blockers before coming to the hospital, who were kept on them

Here:	81.0%
State:	95.2%

Outpatients having surgery who got an antibiotic at the right time - within one hour before surgery (higher numbers are better)

Here:	83.0%
Minnesota:	94.0%

Outpatients having surgery who got the right kind of antibiotic (higher numbers are better)

Here:	90.0%
State:	96.8%

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

Here:	100.0%
State:	99.3%

Outcome of Care

30-Day Mortality Rates from Heart Failure

Here:	11.2%
Minnesota:	11.2%

30-Day Mortality Rates from Pneumonia

Here:	11.6%
Minnesota:	11.4%

30-Day Readmission Rates from Heart Failure

Here:	24.5%
State:	24.3%

30-Day Readmission Rates from Pneumonia

This Nursing Home:	19.8%
State:	18.3%

Use of Medical Imaging

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

This Nursing Home:	7.100%
State:	6.118%

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

This Nursing Home:	0.099%
Minnesota:	0.072%

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

This Nursing Home:	0.018%
Minnesota:	0.011%

LAKEWOOD HEALTH SYSTEM - STAPLES, MN

Hospital Consumer Assessment of Healthcare Providers

Quality Measures

Staff Information

Complaint Deficiency

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

Use of Medical Imaging

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