ST. MARY OF THE WOODS

The information listed below provides an in-depth look into the type and quality of care offered at St. Mary of the Woods. It is important to note that when evaluating if a nursing home is right for you or a loved one, ratings should not be taken as the sole deciding factor, but as one of many aspects to be considered.

Address

ST. MARY OF THE WOODS
35755 DETROIT ROAD
AVON, OH 44011
(440) 937-2700

Nursing Home Ratings

Health Inspections
Quality Measures
Nursing Staff
R.N. Staff Only
Overall Rating

Percent of Beds Occupied

67%

Number of Residents and Certified Beds

  • Residents: 20
  • Certified Beds: 30

This Facility Accepts

  • Medicare

Operational Details

  • Operated By Non Profit - Corporation
  • Offers Only Resident Counseling
  • Part of a Continuing Care Retirement Community (CCRC)
  • This Facility is Part of a Chain or Franchise

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Resident Services

The information below lists services this facility has provided for residents from October through December 2010. During this period, the most common type of service provided was "Ultra-High Rehabilitation". To get a better idea of the types of services that are commonly performed, compare the "Percent of Service Days" column below. These services are based on submitted claims to Medicare and do not provide a complete overview of all the services provided by St. Mary of the Woods. For more information read our guide on how nursing facilities are reimbursed, types of services, and ADL index scores.

Resident ServicesResident ConditionsPercent of Service Days

Ultra-High Rehabilitation

Rehabilitation 720 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
  • A second rehabilitation discipline three days/week
ADL Index Range: 11-165.0%
ADL Index Range: 6-1013.0%
ADL Index Range: 0-526.0%
Total Percent:44.0%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-165.3%
ADL Index Range: 6-109.0%
ADL Index Range: 0-522.0%
Total Percent:36.3%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-161.8%
ADL Index Range: 6-102.6%
ADL Index Range: 0-50.9%
Total Percent:5.3%
 

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum
  • Five days any combination of three rehabilitation disciplines
ADL Index Range: 11-163.8%
ADL Index Range: 6-103.4%
ADL Index Range: 0-51.8%
Total Percent:9.0%
 

Special Care High

  • Comatose
  • Septicemia
  • Diabetes with daily injections and a change of order two or more days
  • Quadriplegia with ADL score greater or equal to 5
  • Chronic Obstructive Pulmonary Disease (COPD) and shortness of breath when lying flat
  • Fever with pneumonia, or vomiting, or weight loss, or feeding tube
  • Parenteral/IV feedings
  • Respiratory therapy for 7 days
  • Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 15-16
- Signs of depression
1.8%
ADL Index Range: 11-14
- No Signs of depression
0.5%
ADL Index Range: 6-10
- Signs of depression
0.5%
ADL Index Range: 6-10
- No Signs of depression
0.1%
ADL Index Range: 2-5
- No Signs of depression
0.7%
Total Percent:3.5%
 

Special Care Low

  • Cerebral palsy, multiple sclerosis, or Parkinson's disease with ADL score greater or equal to 5
  • Respiratory failure and oxygen therapy while a resident
  • Feeding tube where calories >= 51% or calories are in the range of 26-50% and fluid >= 501 mL)
  • Ulcers: 2 or more stage II or 1 or more stage III or IV pressure ulcers
  • Ulcers: 2 or more venous or arterial ulcers
  • Ulcers: 1 stage II pressure ulcer and 1 venous or arterial ulcer with 2 or more skin care treatments
  • Foot infection/diabetic foot ulcer/open lesions of foot with treatment
  • Radiation therapy while a resident
  • Dialysis while a resident
  • Activities of Daily Living (ADL) score of 2 or more
ADL Index Range: 15-16
- Signs of depression
0.6%
ADL Index Range: 11-14
- Signs of depression
1.4%
Total Percent:1.9%
 

Rating Details For St. Mary of the Woods

Nursing Staff -

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Nursing Hours Per Resident Per DayReportedExpected
Registered Nurse (RN) Hours1 Hour and 21 Minutes1 Hour and 21 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours1 Hour and 31 Minutes42 Minutes
Certified Nursing Assistant (CNA) Hours3 Hours and 5 Minutes2 Hours and 20 Minutes
Total Licensed Nurse Hours2 Hours and 51 Minutes2 Hours and 3 Minutes
Total Nurse Hours5 Hours and 56 Minutes4 Hours and 23 Minutes

Quality of Care -

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Ohio are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

This FacilityOhio Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%90%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination67%88%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Were Physically Restrained-5%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection13%11%
Percent of Long-Stay Residents Who Are More Depressed or Anxious33%18%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased17%13%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair3%5%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder10%6%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain2%5%
Percent of Long-Stay Residents Who Lose Too Much Weight8%8%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination69%83%
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season90-100%84%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Had Moderate to Severe Pain31%24%
Percent of Short-Stay Residents Who Have Pressure Sores13%12%
Percent of Short-Stay Residents Who Have Delirium2%3%

Health Inspection Details -

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 09/16/2010.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Administration

Keep Accurate and Appropriate Medical Records.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009
Keep Clinical Information Safe, So That It Will Not Be Lost, Destroyed or Used by the Wrong Person.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009
Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 09/16/2010
  • Correction Date: 10/15/2010

Pharmacy Service

1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009
Properly Mark Drugs and Other Similar Products.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009

Quality Care

Give Professional Services That Meet a Professional Standard of Quality.
  • Inspection Date: 04/17/2008
  • Correction Date: 06/02/2008
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
  • Inspection Date: 04/17/2008
  • Correction Date: 06/02/2008
Give Professional Services That Meet a Professional Standard of Quality.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
  • Inspection Date: 09/16/2010
  • Correction Date: 10/15/2010

Resident Assessment

Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009

Resident Rights

Immediately Tell the Resident, Doctor, and a Family Member If: the Resident is Injured, There is a Major Change in Resident's Physical/Mental Health, There is a Need to Alter Treatment Significantly, or the Resident Must Be Transferred or Discharged.
  • Inspection Date: 04/17/2008
  • Correction Date: 06/02/2008
Provide Services to Meet the Needs and Preferences of Each Resident.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/27/2009

Enforcement

Below is a list of any civil penalities or denials of payment for new admissions (DPNA) that this facility received in the previous three years. Note: Monetary figures are not available for DPNAs.

Action TakenDateAmount
Civil Money Penalty (CMP)09/16/2010$2,405

Fire Safety

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that St. Mary of the Woods had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 09/14/2010.

Degree of Harm

  • - Potential for Minimal Harm
  • - Minimal Harm or Potential for Harm
  • - Resident Harmed
  • - Immediate Jeopardy to Resident Health

Residents Affected

  • - Isolated
  • - Some Residents
  • - Many Residents
Deficiencies Found By InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 04/16/2008
  • Correction Date: 06/02/2008
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 06/22/2009
  • Correction Date: 07/27/2009

Building Service Equipment

Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
  • Inspection Date: 06/22/2009
  • Correction Date: 07/27/2009

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 06/22/2009
  • Correction Date: 07/27/2009
Signs That State That Exit Doors Are to Be Kept Closed.
  • Inspection Date: 06/22/2009
  • Correction Date: 07/27/2009

Electrical

Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 06/22/2009
  • Correction Date: 07/27/2009
Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 09/14/2010
  • Correction Date: 01/07/2011

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
  • Inspection Date: 06/22/2009
  • Correction Date: 07/27/2009

Exits and Egress

Resident Room Doors of Proper Design and Width.
  • Inspection Date: 09/14/2010
  • Correction Date: 01/07/2011

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 04/16/2008
  • Correction Date: 06/02/2008
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 06/22/2009
  • Correction Date: 07/27/2009

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
  • Inspection Date: 06/22/2009
  • Correction Date: 07/27/2009
Source: Medicare Nursing Home Compare; Bureau of Long Term Care of Ohio - Quality Assurance - Retrieved 2011