ST. MARY OF THE WOODS
Address
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
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 Services | Resident Conditions | Percent of Service Days |
Ultra-High Rehabilitation
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
| ADL Index Range: 11-16 | 5.0% |
| ADL Index Range: 6-10 | 13.0% |
| ADL Index Range: 0-5 | 26.0% |
| Total Percent: | 44.0% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 5.3% |
| ADL Index Range: 6-10 | 9.0% |
| ADL Index Range: 0-5 | 22.0% |
| Total Percent: | 36.3% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 1.8% |
| ADL Index Range: 6-10 | 2.6% |
| ADL Index Range: 0-5 | 0.9% |
| Total Percent: | 5.3% |
Medium Rehabilitation
- Five days any combination of three rehabilitation disciplines
| ADL Index Range: 11-16 | 3.8% |
| ADL Index Range: 6-10 | 3.4% |
| ADL Index Range: 0-5 | 1.8% |
| 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 Day | Reported | Expected |
| Registered Nurse (RN) Hours | 1 Hour and 21 Minutes | 1 Hour and 21 Minutes |
| Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 1 Hour and 31 Minutes | 42 Minutes |
| Certified Nursing Assistant (CNA) Hours | 3 Hours and 5 Minutes | 2 Hours and 20 Minutes |
| Total Licensed Nurse Hours | 2 Hours and 51 Minutes | 2 Hours and 3 Minutes |
| Total Nurse Hours | 5 Hours and 56 Minutes | 4 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 Facility | Ohio Average |
Long-Term Stay Preventive Actions
| Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 90% |
| Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 67% | 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 Infection | 13% | 11% |
| Percent of Long-Stay Residents Who Are More Depressed or Anxious | 33% | 18% |
| Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 17% | 13% |
| Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | 3% | 5% |
| Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 10% | 6% |
| Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 2% | 5% |
| Percent of Long-Stay Residents Who Lose Too Much Weight | 8% | 8% |
Short-Term Stay Preventive Actions
| Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 69% | 83% |
| Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 84% |
Short-Term Stay Deficiencies
| Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 31% | 24% |
| Percent of Short-Stay Residents Who Have Pressure Sores | 13% | 12% |
| Percent of Short-Stay Residents Who Have Delirium | 2% | 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 Inspectors | Degree of Harm | Residents Affected |
Administration
Keep Accurate and Appropriate Medical Records.
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Keep Clinical Information Safe, So That It Will Not Be Lost, Destroyed or Used by the Wrong Person.
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Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Have a Program to Keep Infection from Spreading.
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Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Store, Cook, and Give out Food in a Safe and Clean Way.
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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.
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Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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Properly Mark Drugs and Other Similar Products.
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Quality Care
Give Professional Services That Meet a Professional Standard of Quality.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Give Professional Services That Meet a Professional Standard of Quality.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Resident Assessment
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
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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.
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Provide Services to Meet the Needs and Preferences of Each Resident.
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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 Taken | Date | Amount |
| 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 Inspectors | Degree of Harm | Residents Affected |
Automatic Sprinkler Systems
An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
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Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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Building Service Equipment
Heating and Ventilation Systems That Have Been Properly Installed According to the Manufacturer's Instructions.
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Corridor Walls and Doors
Corridor and Hallway Doors That Block Smoke.
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Signs That State That Exit Doors Are to Be Kept Closed.
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Electrical
Weekly Inspections and Monthly Testing of Generators.
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Weekly Inspections and Monthly Testing of Generators.
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Emergency Plans and Fire Drills
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
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Exits and Egress
Resident Room Doors of Proper Design and Width.
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Hazardous Area
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Smoke Compartmentation and Control
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
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