ST. MARYS CARE CENTER

The information listed below provides an in-depth look into the type and quality of care offered at St. Marys Care Center. 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. MARYS CARE CENTER
3401 MAPLE GROVE DR
MADISON, WI 53719
(608) 845-1000

Nursing Home Ratings

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

Percent of Beds Occupied

96%

Number of Residents and Certified Beds

  • Residents: 177
  • Certified Beds: 184

This Facility Accepts

  • Medicare
  • Medicaid

Operational Details

  • Operated By Non Profit - Church Related
  • Offers Both Resident and Family Counseling Services
  • Located Inside of a Hospital Facility
  • This Facility is Part of a Chain or Franchise

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Nearby Cities:

Verona | Middleton | Oregon

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 "Very 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. Marys Care Center. 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

High Rehabilitation Plus Extensive Services

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five 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: 2-107.1%
Total Percent:7.1%
 

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: 6-107.1%
Total Percent:7.1%
 

Very High Rehabilitation

Rehabilitation 500 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-161.3%
ADL Index Range: 6-1011.1%
ADL Index Range: 0-529.8%
Total Percent:42.2%
 

High Rehabilitation

Rehabilitation 325 Minutes Per Week Minimum
  • At least one rehabilitation discipline five days/week
ADL Index Range: 11-166.7%
ADL Index Range: 6-105.8%
ADL Index Range: 0-59.8%
Total Percent:22.2%
 

Medium Rehabilitation

Rehabilitation 150 Minutes Per Week Minimum
  • Five days any combination of three rehabilitation disciplines
ADL Index Range: 11-160.9%
ADL Index Range: 6-1015.1%
Total Percent:16.0%
 

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: 6-10
- No Signs of depression
5.3%
Total Percent:5.3%
 

Rating Details For St. Marys Care Center

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 2 Minutes1 Hour and 17 Minutes
Licensed Practical/Vocational Nurse (LPN/LVN) Hours26 Minutes47 Minutes
Certified Nursing Assistant (CNA) Hours2 Hours and 54 Minutes2 Hours and 31 Minutes
Total Licensed Nurse Hours1 Hour and 28 Minutes2 Hours and 4 Minutes
Total Nurse Hours4 Hours and 22 Minutes4 Hours and 35 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 Vaccination90-100%95%

Long-Term Stay Deficiencies

Percent of Long-Stay Residents Who Were Physically Restrained-3%
Percent of Long-Stay Residents Who Have/Had a Catheter Inserted and Left in Their Bladder15%7%
Percent of Long-Stay Residents Who Lose Too Much Weight4%8%
Percent of High-Risk Long-Stay Residents Who Have Pressure Sores10%8%
Percent of Long-Stay Residents Who Spend Most of Their Time in Bed or in a Chair3%3%
Percent of Long-Stay Residents Whose Need for Help with Daily Activities Has Increased11%14%
Percent of Long-Stay Residents Who Are More Depressed or Anxious21%18%
Percent of Long-Stay Residents Whose Ability to Move About in and Around Their Room Got Worse12%11%
Percent of Low-Risk Long-Stay Residents Who Have Pressure Sores1%3%
Percent of Low-Risk Long-Stay Residents Who Lose Control of Their Bowels or Bladder48%49%
Percent of Long-Stay Residents Who Have Moderate to Severe Pain5%4%
Percent of Long-Stay Residents Who Had a Urinary Tract Infection8%8%

Short-Term Stay Preventive Actions

Percent of Short-Stay Residents Who Were Assessed and Given Pneumococcal Vaccination90-100%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 Had Moderate to Severe Pain37%26%
Percent of Short-Stay Residents Who Have Pressure Sores11%10%
Percent of Short-Stay Residents Who Have Delirium1%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 09/29/2010.

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

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Inspection Date: 04/09/2008
  • Correction Date: 05/07/2008
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/25/2009
Have a Program to Keep Infection from Spreading.
  • Inspection Date: 09/29/2010
  • Correction Date: 10/29/2010

Mistreatment

Keep Each Resident Free from Physical Restraints, Unless Needed for Medical Treatment.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/25/2009
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: 09/29/2010
  • Correction Date: 10/29/2010
Write and Use Policies That Forbid Mistreatment, Neglect and Abuse of Residents and Theft of Residents' Property.
  • Inspection Date: 09/29/2010
  • Correction Date: 10/29/2010

Nutrition and Dietary

Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/25/2009
Prepare Food That is Nutritional, Appetizing, Tasty, Attractive, Well-Cooked, and at the Right Temperature.
  • Inspection Date: 09/29/2010
  • Correction Date: 10/29/2010
Store, Cook, and Give out Food in a Safe and Clean Way.
  • Inspection Date: 09/29/2010
  • Correction Date: 10/29/2010

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: 04/09/2008
  • Correction Date: 05/07/2008
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
  • Inspection Date: 09/29/2010
  • Correction Date: 10/29/2010

Quality Care

Give Professional Services That Meet a Professional Standard of Quality.
  • Inspection Date: 04/09/2008
  • Correction Date: 05/07/2008
Give Professional Services That Follow Each Resident's Written Care Plan.
  • Inspection Date: 04/09/2008
  • Correction Date: 05/07/2008
Give Each Resident Enough Fluids to Keep Them Healthy and Prevent Dehydration.
  • Inspection Date: 04/09/2008
  • Correction Date: 05/07/2008
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/25/2009
Give Professional Services That Follow Each Resident's Written Care Plan.
  • Inspection Date: 09/29/2010
  • Correction Date: 10/29/2010

Resident Assessment

Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Inspection Date: 04/09/2008
  • Correction Date: 05/07/2008
Screen Residents when They Are First Admitted to Send Them to an Area with Special Care for People with Developmental Disabilities or Mental Illness, if Needed.
  • Inspection Date: 06/25/2009
  • Correction Date: 07/25/2009
Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations.
  • Inspection Date: 09/29/2010
  • Correction Date: 10/29/2010

Resident Rights

Tell the Resident Completely About His or Her Health Status.
  • Inspection Date: 09/29/2010
  • Correction Date: 10/29/2010

Deficiencies from Complaints and Incidents

The table below lists incident reports by the nursing staff or administration for St. Marys Care Center, 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 ComplaintsDegree of HarmResidents Affected

Environmental

Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents.
  • Complaint Filed: 03/18/2009
  • Correction Date: 04/18/2009

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.
  • Complaint Filed: 05/04/2009
  • Correction Date: 06/03/2009
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.
  • Complaint Filed: 04/14/2010
  • Correction Date: 05/30/2010

Pharmacy Service

Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly.
  • Complaint Filed: 03/18/2009
  • Correction Date: 04/18/2009

Quality Care

Give Professional Services That Meet a Professional Standard of Quality.
  • Complaint Filed: 10/21/2008
  • Correction Date: 11/11/2008
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible.
  • Complaint Filed: 10/21/2008
  • Correction Date: 11/11/2008

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.
  • Complaint Filed: 10/21/2008
  • Correction Date: 11/11/2008
Try to Resolve Each Resident's Complaints Quickly.
  • Complaint Filed: 03/18/2009
  • Correction Date: 04/18/2009

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. Marys Care Center 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 09/28/2010.

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

Back-Up Procedures in Place for a Faulty Automatic Sprinkler System.
  • Inspection Date: 04/07/2008
  • Correction Date: 05/07/2008
Back-Up Procedures in Place for a Faulty Automatic Sprinkler System.
  • Inspection Date: 06/29/2009
  • Correction Date: 01/01/1900
Automatic Sprinkler Systems That Have Been Maintained in Working Order.
  • Inspection Date: 09/28/2010
  • Correction Date: 10/29/2010

Building Service Equipment

Properly Protected Cooking Facilities.
  • Inspection Date: 09/28/2010
  • Correction Date: 10/29/2010

Electrical

Weekly Inspections and Monthly Testing of Generators.
  • Inspection Date: 04/07/2008
  • Correction Date: 05/07/2008
Properly Installed Electrical Wiring and Equipment.
  • Inspection Date: 06/29/2009
  • Correction Date: 07/25/2009

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
  • Inspection Date: 04/07/2008
  • Correction Date: 05/07/2008
Record of Quarterly Fire Drills for Each Shift Under Varying Conditions.
  • Inspection Date: 09/28/2010
  • Correction Date: 10/29/2010

Exits and Egress

Exits That Are Accessible at All Times.
  • Inspection Date: 04/07/2008
  • Correction Date: 05/07/2008
Exits That Are Accessible at All Times.
  • Inspection Date: 06/29/2009
  • Correction Date: 07/25/2009

Fire Alarm Systems

Properly Maintained Smoke Detectors.
  • Inspection Date: 04/07/2008
  • Correction Date: 05/07/2008
An Approved Back-Up Procedure for a Faulty Fire Alarm System.
  • Inspection Date: 04/07/2008
  • Correction Date: 05/07/2008
An Approved Installation, Maintenance and Testing Program for Fire Alarm Systems.
  • Inspection Date: 06/29/2009
  • Correction Date: 07/25/2009
An Approved Back-Up Procedure for a Faulty Fire Alarm System.
  • Inspection Date: 06/29/2009
  • Correction Date: 01/01/1900
A Fire Alarm System That Can Be Heard Throughout the Facility.
  • Inspection Date: 09/28/2010
  • Correction Date: 10/29/2010
Properly Maintained Smoke Detectors.
  • Inspection Date: 09/28/2010
  • Correction Date: 10/29/2010

Furnishings and Decorations

Restrictions on the Use of Flammable Curtains.
  • Inspection Date: 06/29/2009
  • Correction Date: 07/25/2009
Properly Sized and Located Linen or Trash Receptacles.
  • Inspection Date: 09/28/2010
  • Correction Date: 10/29/2010

Hazardous Area

Properly Installed Hallway Dispensers for Alcohol-Based Hand Rub.
  • Inspection Date: 09/28/2010
  • Correction Date: 10/29/2010

Medical Gases and Anesthetizing Areas

Proper Fire Barriers, Ventilation and Signs for the Transport of Oxygen.
  • Inspection Date: 04/07/2008
  • Correction Date: 05/07/2008

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed.
  • Inspection Date: 09/28/2010
  • Correction Date: 10/29/2010
Source: Medicare Nursing Home Compare; Dept of Health and Family Services of WI-Division of Supportive Living-Bureau of Quality Assurance - Retrieved 2011