VILLA LORETTO NURSING HOME
Address
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
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
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 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 | 6.1% |
ADL Index Range: 6-10 | 34.2% |
Total Percent: | 40.4% |
Very High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 3.1% |
ADL Index Range: 6-10 | 26.3% |
Total Percent: | 29.4% |
High Rehabilitation
- At least one rehabilitation discipline five days/week
ADL Index Range: 11-16 | 3.9% |
ADL Index Range: 6-10 | 7.0% |
ADL Index Range: 0-5 | 3.5% |
Total Percent: | 14.5% |
Medium Rehabilitation
- Five days any combination of three rehabilitation disciplines
ADL Index Range: 6-10 | 6.1% |
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 Day | Reported | Expected |
Registered Nurse (RN) Hours | 53 Minutes | 58 Minutes |
Licensed Practical/Vocational Nurse (LPN/LVN) Hours | 27 Minutes | 38 Minutes |
Certified Nursing Assistant (CNA) Hours | 2 Hours and 37 Minutes | 2 Hours and 40 Minutes |
Total Licensed Nurse Hours | 1 Hour and 19 Minutes | 1 Hour and 36 Minutes |
Total Nurse Hours | 3 Hours and 56 Minutes | 4 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 Facility | Wisconsin Average |
Long-Term Stay Preventive Actions
Percent of Long-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 94% |
Percent of Long-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 88% | 95% |
Long-Term Stay Deficiencies
Percent of Long-Stay Residents Who Lose Too Much Weight | 5% | 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 Bladder | 59% | 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 Bladder | 8% | 7% |
Percent of Long-Stay Residents Who Were Physically Restrained | - | 3% |
Percent of Long-Stay Residents Who Had a Urinary Tract Infection | 14% | 8% |
Percent of Long-Stay Residents Who Are More Depressed or Anxious | 24% | 18% |
Percent of Long-Stay Residents Who Have Moderate to Severe Pain | 5% | 4% |
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased | 18% | 14% |
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse | 11% | 11% |
Short-Term Stay Preventive Actions
Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination | 90% | 92% |
Percent of Short-Stay Residents Given Influenza Vaccination During the Flu Season | 90-100% | 90% |
Short-Term Stay Deficiencies
Percent of Short-Stay Residents Who Have Delirium | 4% | 3% |
Percent of Short-Stay Residents Who Had Moderate to Severe Pain | 35% | 26% |
Percent of Short-Stay Residents Who Have Pressure Sores | 25% | 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 Inspectors | Degree of Harm | Residents Affected |
Administration
Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents.
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Make Sure That Nurse Aides Show They Have the Skills to Be Able to Care for Residents.
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Give or Get Lab Tests to Meet the Needs of Residents.
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Environmental
Have a Program to Keep Infection from Spreading.
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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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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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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
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
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Quality Care
Develop/Implement Required Procedures for the Administration of Immunizations.
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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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Give Professional Services That Follow Each Resident's Written Care Plan.
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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 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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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 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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Automatic Sprinkler Systems That Have Been Maintained in Working Order.
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An Approved Automatic Sprinkler System Connected to the Fire Alarm System.
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Building Construction
A Two-Hour-Resistant Firewall in Common Walls.
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A Two-Hour-Resistant Firewall in Common Walls.
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Approved Construction Type or Materials.
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Building Service Equipment
Properly Constructed Linen or Trash Chutes.
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Properly Protected Cooking Facilities.
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Corridor Walls and Doors
Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of Smoke.
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Corridor and Hallway Doors That Block Smoke.
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Corridor and Hallway Doors That Block Smoke.
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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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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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Fire Alarm Systems
An Approved Back-Up Procedure for a Faulty Fire Alarm System.
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Furnishings and Decorations
Properly Sized and Located Linen or Trash Receptacles.
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Hazardous Area
Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System.
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Illumination and Emergency Power
Proper Backup Exit Lighting.
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Emergency Lighting That Can Last at Least 1 1/2 Hours.
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Emergency Lighting That Can Last at Least 1 1/2 Hours.
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Medical Gases and Anesthetizing Areas
Proper Fire Barriers, Ventilation and Signs for the Transport of Oxygen.
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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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Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour.
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Vertical Openings
Proper Stairway Enclosures and Vertical Shafts.
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Protected Exits That Allow the Resident to Escape the Building.
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