VIRGINIA HIGHLANDS HEALTH AND REHAB
The information listed below provides an in-depth look into the type and quality of care offered at Virginia Highlands Health and Rehab. 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
VIRGINIA HIGHLANDS HEALTH AND REHAB
W173 N10915 BERNIES WAY
GERMANTOWN, WI 53022
(262) 509-3300
W173 N10915 BERNIES WAY
GERMANTOWN, WI 53022
(262) 509-3300
Nursing Home Ratings
| Health Inspections | |
| Quality Measures | |
| Nursing Staff | |
| R.N. Staff Only | |
| Overall Rating | |
Percent of Beds Occupied
87%Number of Residents and Certified Beds
- Residents: 105
- Certified Beds: 121
This Facility Accepts
- Medicare
- Medicaid
Operational Details
- Operated By For Profit - Corporation
- Offers Only Resident Counseling
- This Facility is Part of a Chain or Franchise
Nearby Cities:
New LisbonResident 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 Virginia Highlands Health and Rehab. 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 Plus Extensive Services
Rehabilitation 720 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
- A second rehabilitation discipline three days/week
- Tracheostomy care
- Ventilator or respirator
- Isolation for active infectious disease while a resident
- Activities of Daily Living (ADL) score of 2 or more
| ADL Index Range: 11-16 | 2.7% |
| ADL Index Range: 2-10 | 0.1% |
| Total Percent: | 2.9% |
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: 11-16 | 16.4% |
| ADL Index Range: 6-10 | 40.4% |
| ADL Index Range: 0-5 | 15.4% |
| Total Percent: | 72.2% |
Very High Rehabilitation
Rehabilitation 500 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 4.2% |
| ADL Index Range: 6-10 | 4.6% |
| ADL Index Range: 0-5 | 3.9% |
| Total Percent: | 12.7% |
High Rehabilitation
Rehabilitation 325 Minutes Per Week Minimum
- At least one rehabilitation discipline five days/week
| ADL Index Range: 11-16 | 2.1% |
| ADL Index Range: 6-10 | 3.3% |
| Total Percent: | 5.4% |
Medium Rehabilitation
Rehabilitation 150 Minutes Per Week Minimum
- Five days any combination of three rehabilitation disciplines
| ADL Index Range: 11-16 | 1.0% |
| ADL Index Range: 6-10 | 0.2% |
| ADL Index Range: 0-5 | 0.2% |
| Total Percent: | 1.5% |
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 - No Signs of depression | 0.7% |
| ADL Index Range: 11-14 - No Signs of depression | 0.06% |
| Total Percent: | 0.7% |
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 - No Signs of depression | 1.7% |
| ADL Index Range: 11-14 - No Signs of depression | 0.8% |
| ADL Index Range: 6-10 - No Signs of depression | 0.8% |
| Total Percent: | 3.3% |
Clinically Complex
- Pneumonia, hemiplegia with ADL score >=5
- Surgical wounds or open lesions with treatment
- Burns
- Chemotherapy while a resident
- Oxygen therapy while a resident
- IV medications or transfusions while a resident
- Extensive Services, Special Care High or Special Care Low qualifier and ADL score of 0 or 1
| ADL Index Range: 2-5 - No Signs of depression | 0.2% |
| Total Percent: | 0.2% |
Reduced Physical Function
- Urinary and/or bowel training program
- Passive and/or active range of motion (ROM)
- Amputation/prosthesis training
- Dressing or grooming training
- Eating or swallowing training
- Transfer training
- Splint or brace assistance
- Bed mobility and/or walking training
- Communication training
| ADL Index Range: 11-14 - Less restorative nursing | 0.2% |
| ADL Index Range: 6-10 - Less restorative nursing | 0.8% |
| ADL Index Range: 0-1 - Less restorative nursing | 0.2% |
| Total Percent: | 1.2% |
Rating Details For Virginia Highlands Health and Rehab
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 | 41 Minutes | 1 Hour and 12 Minutes |
| Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 53 Minutes | 42 Minutes |
| Certified Nursing Assistant (CNA) Hours | 2 Hours and 23 Minutes | 2 Hours and 29 Minutes |
| Total Licensed Nurse Hours | 1 Hour and 34 Minutes | 1 Hour and 54 Minutes |
| Total Nurse Hours | 3 Hours and 57 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 Wisconsin are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.
| This Facility | Wisconsin Average |
Long-Term Stay Preventive Actions
| Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 95% |
| Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 94% |
Long-Term Stay Deficiencies
| Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder | 47% | 49% |
| Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 11% | 14% |
| Percent of Long-Stay Residents Who Lose Too Much Weight | 7% | 8% |
| Percent of Long-Stay Residents Who Were Physically Restrained | - | 3% |
| Percent of High-Risk Long-Stay Residents Who Have Pressure Sores | 5% | 8% |
| Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 7% | 8% |
| Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 2% | 4% |
| Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder | 5% | 7% |
| Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores | - | 3% |
| Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 16% | 11% |
| Percent of Long-Stay Residents Who Are More Depressed or Anxious | 14% | 18% |
| Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair | - | 3% |
Short-Term Stay Preventive Actions
| Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 75% | 90% |
| Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90-100% | 92% |
Short-Term Stay Deficiencies
| Percent of Short-Stay Residents Who Have Delirium | 1% | 3% |
| Percent of Short-Stay Residents Who Have Pressure Sores | 7% | 10% |
| Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 15% | 26% |
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 06/30/2011.
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
1) Review the Work of Each Nurse Aide Every Year; or 2) Give Regular Training for the Nurse Aides.
|  |  |
Nutrition and Dietary
Store, Cook, and Give out Food in a Safe and Clean Way.
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Pharmacy Service
Make Sure That Residents Are Safe from Serious Medication Errors.
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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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Make Sure That Residents Are Safe from Serious Medication Errors.
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Quality Care
Give Professional Services That Meet a Professional Standard of Quality.
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Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
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Give Professional Services That Meet a Professional Standard of Quality.
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Resident Assessment
Make Sure All Assessments Are Accurate, Coordinated by an Rn, Done by the Right Professional, and Are Signed by the Person Completing Them.
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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 Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect.
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Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help.
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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) | 07/15/2009 | $1,950 |
| Civil Money Penalty (CMP) | 03/24/2009 | $22,200 |
| Civil Money Penalty (CMP) | 03/24/2009 | $177,800 |
Deficiencies from Complaints and Incidents
The table below lists incident reports by the nursing staff or administration for Virginia Highlands Health and Rehab, as well as complaints by residents or their family in the previous three years.
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
| Formal Complaints | Degree of Harm | Residents Affected |
Administration
Keep Accurate and Appropriate Medical Records.
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Environmental
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
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Mistreatment
1) Hire Only People Who Have 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.
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1) Hire Only People Who Have 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.
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Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
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Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
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1) Hire Only People Who Have 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.
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Quality Care
Give Each Resident Enough Fluids to Keep Them Healthy and Prevent Dehydration.
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Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
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Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
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Resident Assessment
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
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Resident Rights
Tell Each Resident Who Can Get Medicaid Benefits About 1) Which Items and Services Medicaid Covers and Which the Resident Must Pay For; or 2) How to Apply for Medicaid, Along with the Names and Addresses of State Groups That Can Help.
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Make Sure Each Resident Has the Right to Choose Activities, Schedules and Health Care According to His or Her Interests, Assessment, and Plan of Care.
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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 Virginia Highlands Health and Rehab 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 06/28/2011.
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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Back-Up Procedures in Place for a Faulty Automatic Sprinkler System.
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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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Back-Up Procedures in Place for a Faulty Automatic Sprinkler System.
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Building Construction
A Two-Hour-Resistant Firewall in Common Walls.
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Building Service Equipment
Properly Protected Cooking Facilities.
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Properly Constructed Linen or Trash Chutes.
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An Externally Vented Heating System.
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Corridor Walls and Doors
Corridor and Hallway Doors That Block Smoke.
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Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of 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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Properly Installed Electrical Wiring and Equipment.
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Emergency Plans and Fire Drills
Did Not Have a Written Emergency Evacuation Plan.
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Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
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Exits and Egress
Exits That Are Accessible at All Times.
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Fire Alarm Systems
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
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An Approved Back-Up Procedure for a Faulty Fire Alarm System.
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Furnishings and Decorations
Exits That Are Free from Obstructions and Can Be Used at All Times.
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Properly Sized and Located Linen or Trash Receptacles.
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Exits That Are Free from Obstructions and Can Be Used at All Times.
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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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Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Illumination and Emergency Power
Emergency Lighting That Can Last at Least 1 1/2 Hours.
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Miscellaneous
Fire Safety Features Required by Current Fire Safety Codes.
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Smoke Compartmentation and Control
Smoke Barrier Doors That Can Resist Smoke for at Least 20 Minutes.
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Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
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Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
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Source: Medicare Nursing Home Compare; Dept of Health and Family Services of WI-Division of Supportive Living-Bureau of Quality Assurance - Retrieved 2011
