VILLA MARIA HEALTH AND REHAB CTR

Nursing Home Inspector

300 VILLA DR
HURLEY, WI 54534
Iron County
Phone: 715-561-3200
Provider Number: 525540
Last Inspection: 10/04/2017

About the Nursing Home

Number of Beds: 70
Number of Residents: 64
Beds Available: 6
Percent Occupancy: 91%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

3

Facility
1

County
19

WI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

3

2017
17

2016
35

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

10/4/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3  
 

9/8/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Isolated : Minimal 3 10/21/2016
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 10/21/2016
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 10/21/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 10/21/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 10/21/2016
 

8/19/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 9/19/2015
 
Failed To: Provide a safe, clean, comfortable and home-like environment; and allow residents to use personal belongings to the extent possible. Pattern : Minimal 4 9/19/2015
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 9/19/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 9/19/2015
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 9/19/2015
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 9/19/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 9/19/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 9/19/2015
 
Failed To: 1) Receive registry verification that a nurse aide has met the required training and skills that the State requires; and 2) ensure nurse aides receive the required retraining after 24 months if nursing related services were not provided for monetary compe Widespread : Minimal 5 9/19/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

7/15/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 7/22/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg WI State Avg
Number of Residents 64 46.00 64.95
Registered Nurses 0.73 0.77 1.00
Licensed Practical / Vocational Nurses 0.57 0.54 0.56
Certified Nursing Assistants 2.42 2.21 2.54
Total Staff Hours 3.72 3.51 4.11

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% WI State Avg%
of high risk long-stay residents with pressure ulcers 0 1 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 100 98
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 98 96
of long-stay residents experiencing one or more falls with major injury 4 5 3
of long-stay residents who have depressive symptoms 0 0 5
of long-stay residents who lose too much weight 10 8 7
of long-stay residents who received an antianxiety or hypnotic medication 10 15 18
of long-stay residents who received an antipsychotic medication 2 7 12
of long-stay residents who self-report moderate to severe pain 8 8 7
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 9 15 18
of long-stay residents whose need for help with daily activities has increased 11 17 13
of long-stay residents with a catheter inserted and left in their bladder 5 2 2
of long-stay residents with a urinary tract infection 5 3 3
of low risk long-stay residents who lose control of their bowels or bladder 40 33 46
of short-stay residents assessed and appropriately given the pneumococcal vaccine 96 96 90
of short-stay residents who had an outpatient emergency department visit 23 23 12
of short-stay residents who made improvements in function 54 54 74
of short-stay residents who newly received an antipsychotic medication 6 6 1
of short-stay residents who self-report moderate to severe pain 21 21 18
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 94 66 86
of short-stay residents who were rehospitalized after a nursing home admission 13 13 18
of short-stay residents who were successfully discharged to the community 47 47 61
of short-stay residents with pressure ulcers that are new or worsened 0 0 0