ATRIUM POST ACUTE CARE OF PLYMOUTH

Nursing Home Inspector

916 E CLIFFORD ST
PLYMOUTH, WI 53073
Sheboygan County
Phone: 920-893-4777
Provider Number: 525685
Last Inspection: 05/10/2017

About the Nursing Home

Number of Beds: 60
Number of Residents: 30
Beds Available: 30
Percent Occupancy: 50%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
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

 

35

Facility
23

County
19

WI
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

35

2017
7

2016
6

2015

Medicare Ratings

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

 

Details by Inspection Date

5/10/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Pattern : Minimal 4 6/9/2017
 
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 6/9/2017
 
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 6/9/2017
 
Failed To: Allow residents to easily view the results of the nursing home's most recent inspection. Widespread : Potential 4 6/9/2017
 
Failed To: Allow residents to self-administer drugs if determined safe. Isolated : Minimal 3 6/9/2017
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 5/16/2017
 
Failed To: Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. Isolated : Minimal 3 6/9/2017
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 6/9/2017
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 6/9/2017
 
Failed To: Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. Isolated : Minimal 3 6/9/2017
 
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 6/9/2017
 

4/6/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Give residents a notice of rights, rules, services and charges. Isolated : Minimal 3 4/27/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 4/27/2016
 

3/23/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
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 4/8/2015
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 4/8/2015
 

Complaint Investigation Deficiencies

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

6/13/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 7/13/2016
 
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 7/13/2016
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Isolated : Minimal 3 7/13/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg WI State Avg
Number of Residents 30 61.00 64.95
Registered Nurses 0.72 0.96 1.00
Licensed Practical / Vocational Nurses 0.63 0.62 0.56
Certified Nursing Assistants 2.02 2.25 2.54
Total Staff Hours 3.37 3.82 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 5 4 4
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 98 98
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 98 96
of long-stay residents experiencing one or more falls with major injury 6 4 3
of long-stay residents who have depressive symptoms 2 3 5
of long-stay residents who lose too much weight 12 8 7
of long-stay residents who received an antianxiety or hypnotic medication 24 22 18
of long-stay residents who received an antipsychotic medication 19 12 12
of long-stay residents who self-report moderate to severe pain 14 7 7
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 22 20 18
of long-stay residents whose need for help with daily activities has increased 16 14 13
of long-stay residents with a catheter inserted and left in their bladder 1 2 2
of long-stay residents with a urinary tract infection 4 2 3
of low risk long-stay residents who lose control of their bowels or bladder 65 50 46
of short-stay residents assessed and appropriately given the pneumococcal vaccine 91 91 90
of short-stay residents who had an outpatient emergency department visit 5 8 12
of short-stay residents who made improvements in function 79 81 74
of short-stay residents who newly received an antipsychotic medication 2 0 1
of short-stay residents who self-report moderate to severe pain 32 17 18
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 81 89 86
of short-stay residents who were rehospitalized after a nursing home admission 20 15 18
of short-stay residents with pressure ulcers that are new or worsened 0 73 61