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MARYHILL MANOR - NIAGARA, WI

 



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Address
501 MADISON AVE
NIAGARA, WI, 54151
Phone (make sure to verify first before calling): (715) 251-3172

Number of Certified Beds: 75
Total Number of Residents: 71
Percent of Occupied Beds: 95%
Sprinkler Status: Fully Sprinklered
Program Participation: Medicare and Medicaid
Type of Ownership: Non profit - Church related
Located Within a Hospital?: No
Multi Nursing Home Ownership?: No
Resident and Family Councils: Resident
Continuing Care Retirement Community?: No
Quality Indicator Survey?: No
Special Focus Facility?: No
Type: Skilled Nursing Facilities


Overall Star Rating: 2 Stars
Health Inspections Star Rating: 1 Star
Nurse Staffing Star Rating: 4 Stars
Quality Measures Star Rating: 4 Stars
RN Only Star Rating: 4 Stars

Employment Full-Time Equivalent

Administrative Staff - Full Time: 1.14
Certified Nurse Aides - Full Time: 17.09
Certified Nurse Aides - Part Time: 17.69
Dietitians - Under Contract: 0.11
Food Service Personnel - Full Time: 2.37
Food Service Personnel - Part Time: 5.74
Housekeeping Personnel - Full Time: 4.24
Licensed Practical/ Vocational Nurses - Full Time: 2.23
Licensed Practical/ Vocational Nurses - Part Time: 2.17
Medical Directors - Under Contract: 0.06
Nurses With Administrative Duties - Full Time: 1.14
Persons Not Included In Any Other Categories - Full Time: 5.79
Physical Therapists - Under Contract: 0.07
Registered Nurses - Full Time: 2.53
Rn Director Of Nursing - Full Time: 1.14
Social Workers - Full Time: 1.14
Activities Professionals - Full Time: 1.14
Occupational Therapists - Under Contract: 1.14
Speech Pathologists - Under Contract: 0.29
Other Physicians - Under Contract: 0.04
Persons Not Included In Any Other Categories - Part Time: 0.56
Registered Nurses - Part Time: 4.29
Housekeeping Personnel - Part Time: 5.36
Physical Therapy Aide - Under Contract: 0.69
Nurse Aides In Training - Part Time: 3.00
Occupational Therapy Aides - Under Contract: 0.60

Provided Services

  • Activities Services Are Provided Onsite To Residents
  • Clinical Laboratory Services Are Provided Offsite To Residents
  • Clinical Laboratory Services Are Provided Onsite To Residents
  • Dental Services Are Provided Offsite To Residents
  • Dental Services Are Provided Onsite To Residents
  • Diagnostic Xray Services Are Provided Offsite To Residents
  • Dietary Services Are Provided Offsite To Residents
  • Dietary Services Are Provided Onsite To Residents
  • Housekeeping Services Are Provided Onsite To Residents
  • Mental Health Services Are Provided Offsite To Residents
  • Nursing Services Are Provided Onsite To Residents
  • Occupational Therapy Services Are Provided Onsite To Non Residents
  • Occupational Therapy Services Are Provided Onsite To Residents
  • Pharmacy Services Are Provided Offsite To Residents
  • Pharmacy Services Are Provided Onsite To Residents
  • Physical Therapy Services Are Provided Onsite To Non Residents
  • Physical Therapy Services Are Provided Onsite To Residents
  • Physician Services Are Provided Offsite To Residents
  • Physician Services Are Provided Onsite To Residents
  • Podiatry Services Are Provided Offsite To Residents
  • Podiatry Services Are Provided Onsite To Residents
  • Social Work Services Are Provided Onsite To Residents
  • Speech/Language Pathology Services Are Provided Onsite To Non Residents
  • Speech/Language Pathology Services Are Provided Onsite To Residents

Staff Information

Number of Registered Nurses Hours Per Resident Per Day
Here:

0.850
Wisconsin:

0.887
Number of Licensed Practical and Licensed Vocational Nurses Hours Per Resident Per Day
Here:

0.360
Wisconsin:

0.546
Total Number of Licensed Staff Hours Per Resident Per Day
Here:

1.210
State:

1.429
Number of ,Certified Nurse Assistant Hours Per Resident Per Day
This Nursing Home:

0.010
State:

0.074
Number Therapy Hours Per Resident Per Day
This Nursing Home:

0.010
Wisconsin:

0.079

Quality Measures

Percent of long-stay residents whose need for help with daily activities has increased
This Nursing Home:

16.4%
State:

15.6%
Percent of long-stay residents who self-report moderate to severe pain
This Nursing Home:

21.1%
State:

11.2%
Percent of long-stay high-risk residents with pressure ulcers
Here:

11.4%
State:

4.6%
Percent of long-stay residents who lose too much weight
This Nursing Home:

13.8%
Wisconsin:

7.2%
Percent of long-stay low-risk residents who lose control of their bowels or bladder
Here:

48.4%
State:

45.0%
Percent of long-stay residents who have had a catheter inserted and left in their bladder
This Nursing Home:

4.1%
State:

4.7%
Percent of long-stay residents with a urinary tract infection
This Nursing Home:

5.2%
State:

6.4%
Percent of long-stay residents who have depressive symptoms
Here:

1.7%
State:

6.9%
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
This Nursing Home:

100.0%
Wisconsin:

98.4%
Percent of short-stay residents who self-report moderate to severe pain
This Nursing Home:

21.4%
Wisconsin:

21.8%
Percent of short-stay residents with Pressure ulcers that are new or worsened
This Nursing Home:

2.0%
Wisconsin:

1.6%
Percent of short-stay residents assessed and given, appropriately, the seasonal influenza vaccine
This Nursing Home:

100.0%
State:

92.1%
Percent of short-stay residents assessed and given, appropriately, the pneumococcal vaccine
Here:

100.0%
Wisconsin:

92.0%
Percent of long-stay residents who received an antipsychotic medication
Here:

14.3%
State:

18.8%

Complaint Deficiency

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Few (Minimal harm or potential for actual harm)

Follow policies and procedures to convey the resident's personal funds to the appropriate party responsible after the resident's death: Few (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Few (Minimal harm or potential for actual harm)

Keep accurate, complete and organized clinical records on each resident that meet professional standards: Few (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Some (Actual harm)

Employ or obtain outside professional resources providing services in the nursing home that meet professional standards: Some (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Few (Immediate jeopardy to resident health or safety)

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: Few (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Some (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Many (Potential for minimal harm)

Corridors that are separated from common areas by walls constructed to limit the passage of smoke: Some (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Some (Minimal harm or potential for actual harm)

Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour: Many (Minimal harm or potential for actual harm)

Smoke barrier doors that can resist smoke for at least 20 minutes: Some (Minimal harm or potential for actual harm)

Construction that can resist fire for one hour or an approved fire extinguishing system: Few (Minimal harm or potential for actual harm)

Exits that are accessible at all times: Some (Minimal harm or potential for actual harm)

Proper backup exit lighting: Some (Minimal harm or potential for actual harm)

Emergency lighting that can last at least 1 1/2 hours: Some (Minimal harm or potential for actual harm)

Record of quarterly fire drills for each shift under varying conditions: Many (Minimal harm or potential for actual harm)

A fire alarm system that can be heard throughout the facility: Many (Minimal harm or potential for actual harm)

An approved installation, maintenance and testing program for fire alarm systems: Many (Minimal harm or potential for actual harm)

Properly maintained smoke detectors: Many (Minimal harm or potential for actual harm)

An approved automatic sprinkler system connected to the fire alarm system: Many (Minimal harm or potential for actual harm)

Automatic sprinkler systems that have been maintained in working order: Some (Minimal harm or potential for actual harm)

Proper fire barriers, ventilation and signs for the transport of oxygen: Some (Minimal harm or potential for actual harm)

Weekly inspections and monthly testing of generators: Many (Minimal harm or potential for actual harm)

Properly installed electrical wiring and equipment: Few (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Review or revise the resident's care plan after any major change in a resident's physical or mental health: Few (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Provide care by qualified persons according to each resident's written plan of care: Few (Minimal harm or potential for actual harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Few (Minimal harm or potential for actual harm)

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: Few (Minimal harm or potential for actual harm)

Provide food in a way that meets a resident's needs: Few (Minimal harm or potential for actual harm)

Store, cook, and serve food in a safe and clean way: Few (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Some (Minimal harm or potential for actual harm)

Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs: Some (Minimal harm or potential for actual harm)

Keep each resident's personal and medical records private and confidential: Few (Minimal harm or potential for actual harm)

Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured: Few (Minimal harm or potential for actual harm)

Provide care by qualified persons according to each resident's written plan of care: Few (Minimal harm or potential for actual harm)

Assist those residents who need total help with eating/drinking, grooming and personal and oral hygiene: Few (Minimal harm or potential for actual harm)

Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores: Few (Minimal harm or potential for actual harm)

Develop policies and procedures for influenza and pneumococcal immunizations: Some (Potential for minimal harm)

Safely provide drugs and other similar products available, which are needed every day and in emergencies, by a licensed pharmacist: Some (Minimal harm or potential for actual harm)

Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards: Few (Minimal harm or potential for actual harm)

Have a program that investigates, controls and keeps infection from spreading: Many (Minimal harm or potential for actual harm)

Corridor and hallway doors that block smoke: Some (Minimal harm or potential for actual harm)

Did not have a written emergency evacuation plan: Many (Potential for minimal harm)

Record of quarterly fire drills for each shift under varying conditions: Many (Potential for minimal harm)

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