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Epione Pavillion

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About Epione Pavillion

General Information

Legal Business NameSouthwest Health Center, Inc
Ownership TypeNon Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJanuary 1, 1986 (31 years)
Capacity78
Residents75
Percent Occupied96%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalYes
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Epione Pavillion

Epione Pavillion
was reviewed by Medicare to have a rating of 4 out of 5. About Medicare Ratings
Overall Rating
Health Inspections Rating
Quality Measures Rating
Staff Rating
RN Staff Rating

Overall Ratings of Wisconsin Nursing Homes

Fines, Complaints, and Inspection Problems in the Past 3 Years

Compare The Number of Problems

Types of Problems at Nursing Homes

Some issues within a nursing home are much more severe than others. Medicare evaluates each problem based on 2 scales: the number of residents affected by a problem and the severity of the potential or actual harm to residents based on the problem. We have color coded the matrix below to make it easier to pick out the more severe problems. In general, orange and red issues related to the treatment of a resident are considered substandard quality of care.

  Residents Affected
Severity of the Deficiency Few Some Many
Immediate jeopardy to resident health or safety J K L
Actual harm that is not immediate jeopardy G H I
No actual harm with potential for more than minimal harm that is not immediate jeopardy D E F
No actual harm with potential for minimal harm A B C

October 8, 2015 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
ESomePotential for HarmHealth InspectionEnsure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions.
DFewPotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
DFewPotential for HarmHealth InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmHealth InspectionKeep each resident free from physical restraints, unless needed for medical treatment.
DFewPotential for HarmHealth Inspection1) Hire only people with 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.
DFewPotential for HarmHealth InspectionProvide medically-related social services to help each resident achieve the highest possible quality of life.
DFewPotential for HarmHealth InspectionAllow residents to self-administer drugs if determined safe.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.

October 6, 2015 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
ESomePotential for HarmFire Safety InspectionProperly installed hallway dispensers for alcohol-based hand rub.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
DFewPotential for HarmFire Safety InspectionProperly located and lighted "Exit" signs.
DFewPotential for HarmFire Safety InspectionExit stairways and towers that are smoke proof.

August 21, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.
DFewPotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
DFewPotential for HarmHealth InspectionEnsure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
DFewPotential for HarmHealth InspectionEnsure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care.
DFewPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Epione Pavillion require. It is important to compare the reported time to expected time for a single facility instead of comparing the amount of time per resident of two facilities. Learn why.

2hr 25min
2hr 40min
ReportedExpected
CNA
25min
35min
ReportedExpected
LPN
60min
55min
ReportedExpected
RN
3hr 50min
4hr 10min
ReportedExpected
Total Nursing

This facility also provides approximately 35min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

100.0%
100.0%
100.0%
97.6%
Q1 2015Q2 2015Q3 2015WI
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
100.0%
100.0%
97.9%
Q1 2015Q2 2015Q3 2015WI
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
45.1%
Q1 2015Q2 2015Q3 2015WI
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
19.1%
21.1%
20.6%
13.3%
Q1 2015Q2 2015Q3 2015WI
Received an Antipsychotic Medication
16.9%
14.8%
9.7%
14.3%
Q1 2015Q2 2015Q3 2015WI
Need for Help with ADLs has Increased
9.6%
12.0%
11.7%
9.3%
Q1 2015Q2 2015Q3 2015WI
Self Report Moderate to Severe Pain
4.5%
7.1%
6.0%
7.5%
Q1 2015Q2 2015Q3 2015WI
Lose Too Much Weight
1.6%
0.0%
0.0%
4.3%
Q1 2015Q2 2015Q3 2015WI
High Risk Residents With Pressure Ulcers
0.0%
0.0%
0.0%
5.6%
Q1 2015Q2 2015Q3 2015WI
Have Depressive Symptoms
0.0%
4.3%
1.5%
4.5%
Q1 2015Q2 2015Q3 2015WI
With a Urinary Tract Infection
1.5%
1.4%
1.5%
3.1%
Q1 2015Q2 2015Q3 2015WI
Experiencing One or More Falls with Major Injury
8.5%
11.7%
16.9%
3.9%
Q1 2015Q2 2015Q3 2015WI
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.4%
Q1 2015Q2 2015Q3 2015WI
Were Physically Restrained

Quality Measures for Short Stay Residents

100.0%
94.3%
97.4%
89.6%
Q1 2015Q2 2015Q3 2015WI
Assessed and Appropriately Given the Pneumococcal Vaccine
100.0%
100.0%
100.0%
88.4%
Q1 2015Q2 2015Q3 2015WI
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
22.2%
24.0%
10.3%
20.3%
Q1 2015Q2 2015Q3 2015WI
Self Report Moderate to Severe Pain
0.0%
0.0%
0.0%
1.2%
Q1 2015Q2 2015Q3 2015WI
Newly Received an Antipsychotic Medication
1.7%
0.0%
0.0%
1.0%
Q1 2015Q2 2015Q3 2015WI
With Pressure Ulcers That Are New or Worsened