VILLA LORETTO NURSING HOME

The information listed below provides an in-depth look into the type and quality of care offered at Villa Loretto Nursing Home. 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

VILLA LORETTO NURSING HOME
N8114 COUNTY WW
MOUNT CALVARY, WI 53057
(920) 753-3211

Nursing Home Ratings

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

Percent of Beds Occupied

100%

Number of Residents and Certified Beds

  • Residents: 52
  • Certified Beds: 52

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By Non Profit - Church Related
  • Offers Only Resident Counseling
  • This Facility is Not Part of a Chain or Franchise

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Nearby Cities:

New Holstein | Plymouth | Chilton

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 Villa Loretto Nursing Home. 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: 11-166.1%
ADL Index Range: 6-1034.2%
Total Percent:40.4%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-163.1%
ADL Index Range: 6-1026.3%
Total Percent:29.4%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-163.9%
ADL Index Range: 6-107.0%
ADL Index Range: 0-53.5%
Total Percent:14.5%
 

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum
  • Five days any combination of three rehabilitation disciplines
ADL Index Range: 6-106.1%
Total Percent:6.1%
 

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: 6-10
- No Signs of depression
9.6%
Total Percent:9.6%
 

Rating Details For Villa Loretto Nursing Home

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) Hours53 Minutes58 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours27 Minutes38 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 37 Minutes2 Hours and 40 Minutes
Total Licensed Nurse Hours1 Hour and 19 Minutes1 Hour and 36 Minutes
Total Nurse Hours3 Hours and 56 Minutes4 Hours and 16 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 FacilityWisconsin Average

Long-Term Stay Preventive Actions

Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season90-100%94%
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination88%95%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Lose Too Much Weight5%8%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair-3%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder59%49%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores-8%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder8%7%
Percent of Long-Stay Residents Who Were Physically Restrained-3%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection14%8%
Percent of Long-Stay Residents Who Are More Depressed or Anxious24%18%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain5%4%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased18%14%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse11%11%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90%92%
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season90-100%90%

Short-Term Stay Deficiencies

Percent of Short-Stay Residents Who Have Delirium4%3%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain35%26%
Percent of Short-Stay Residents Who Have Pressure Sores25%10%

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 04/15/2011.

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 InspectorsDegree of HarmResidents Affected

Administration

Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011
Give or Get Lab Tests to Meet the Needs of Residents.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011

Environmental

Have a Program to Keep Infection from Spreading.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011

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.
  • Inspection Date: 02/06/2009
  • Correction Date: 03/06/2009

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011

Pharmacy Service

Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011

Quality Care

Develop/Implement Required Procedures for the Administration of Immunizations.
  • Inspection Date: 02/06/2009
  • Correction Date: 03/06/2009
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Give Professional Services That Follow Each Resident's Written Care Plan.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011

Resident Assessment

Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured.
  • Inspection Date: 04/15/2011
  • Correction Date: 05/15/2011

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 Villa Loretto Nursing Home 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 04/14/2011.

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 InspectorsDegree of HarmResidents Affected

Automatic Sprinkler Systems

An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/19/2009
Back-Up Procedures in Place for a Faulty Automatic Sprinkler System.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/06/2009
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
  • Inspection Date: 04/14/2011
  • Correction Date: 04/26/2011

Building Construction

A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/19/2009
A Two-Hour-Resistant Firewall in Common Walls.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Approved Construction Type or Materials.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010

Building Service Equipment

Properly Constructed Linen or Trash Chutes.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/19/2009
Properly Protected Cooking Facilities.
  • Inspection Date: 03/09/2010
  • Correction Date: 03/29/2010

Corridor Walls and Doors

Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of Smoke.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Corridor and Hallway Doors That Block Smoke.
  • Inspection Date: 04/14/2011
  • Correction Date: 04/26/2011

Electrical

Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/19/2009
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/19/2009
Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 03/09/2010
  • Correction Date: 03/11/2010
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 03/09/2010
  • Correction Date: 03/09/2010

Emergency Plans and Fire Drills

Did Not Have a Written Emergency Evacuation Plan.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/06/2009

Fire Alarm Systems

An Approved Back-Up Procedure for a Faulty Fire Alarm System.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/06/2009

Furnishings and Decorations

Properly Sized and Located Linen or Trash Receptacles.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/19/2009

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010

Illumination and Emergency Power

Proper Backup Exit Lighting.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/19/2009
Emergency Lighting That Can Last at Least 1 1/2 Hours.
  • Inspection Date: 02/11/2009
  • Correction Date: 03/19/2009
Emergency Lighting That Can Last at Least 1 1/2 Hours.
  • Inspection Date: 03/09/2010
  • Correction Date: 03/11/2010

Medical Gases and Anesthetizing Areas

Proper Fire Barriers, Ventilation and Signs for the Transport of Oxygen.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
  • Inspection Date: 04/14/2011
  • Correction Date: 04/26/2011

Vertical Openings

Proper Stairway Enclosures and Vertical Shafts.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Protected Exits That Allow the Resident to Escape the Building.
  • Inspection Date: 03/09/2010
  • Correction Date: 04/18/2010
Source: Medicare Nursing Home Compare; Dept of Health and Family Services of WI-Division of Supportive Living-Bureau of Quality Assurance - Retrieved 2011