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Tivoli At Divine Savior Healthcare

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About Tivoli At Divine Savior Healthcare

General Information

Legal Business NameDivine Savior Healthcare, Inc
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJuly 24, 1993 (23 years)
Capacity83
Residents68
Percent Occupied82%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalYes
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Tivoli At Divine Savior Healthcare

Tivoli At Divine Savior Healthcare
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

August 13, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
ESomePotential 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.
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.
DFewPotential for HarmHealth InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
DFewPotential for HarmHealth InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
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 InspectionProvide care by qualified persons according to each resident's written plan of care.
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.

August 11, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionHeating and ventilation systems that have been properly installed according to the manufacturer's instructions.
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
FManyPotential for HarmFire Safety InspectionAn approved installation, maintenance and testing program for fire alarm systems.
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 InspectionProperly installed electrical wiring and equipment.
ESomePotential for HarmFire Safety InspectionAutomatic sprinkler systems that have been maintained in working order.
ESomePotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
ESomePotential for HarmFire Safety InspectionCorridor and hallway doors that block smoke.
ESomePotential for HarmFire Safety InspectionExits that are accessible at all times.

July 3, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaint+InspectionDevelop policies and procedures for influenza and pneumococcal immunizations.
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 InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
DFewPotential for HarmHealth InspectionConduct initial and periodic assessments of each resident's functional capacity.

July 1, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionAn approved automatic sprinkler system connected to the fire alarm system.
FManyPotential for HarmFire Safety InspectionRecord of quarterly fire drills for each shift under varying conditions.
ESomePotential for HarmFire Safety InspectionProperly constructed linen or trash chutes.
ESomePotential for HarmFire Safety InspectionRooms that can be unlocked from inside without a key.
ESomePotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.
DFewPotential for HarmFire Safety InspectionProper fire barriers, ventilation and signs for the transfilling of oxygen.

January 30, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure 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 HarmComplaintProvide care by qualified persons according to each resident's written plan of care.

April 3, 2013 - 4 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$9,718 fine

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Tivoli At Divine Savior Healthcare 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.

3hr 35min
2hr 35min
ReportedExpected
CNA
20min
40min
ReportedExpected
LPN
1hr 35min
1hr
ReportedExpected
RN
5hr 30min
4hr 15min
ReportedExpected
Total Nursing

This facility also provides approximately 1hr 5min per resident per WEEK of physical therapist time.

Quality Measures for Long Stay Residents

98.4%
97.1%
97.1%
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
14.8%
9.3%
12.3%
13.3%
Q1 2015Q2 2015Q3 2015WI
Received an Antipsychotic Medication
31.8%
12.8%
7.5%
14.3%
Q1 2015Q2 2015Q3 2015WI
Need for Help with ADLs has Increased
7.9%
17.8%
11.1%
9.3%
Q1 2015Q2 2015Q3 2015WI
Self Report Moderate to Severe Pain
16.7%
16.4%
12.1%
7.5%
Q1 2015Q2 2015Q3 2015WI
Lose Too Much Weight
8.2%
11.6%
10.2%
4.3%
Q1 2015Q2 2015Q3 2015WI
High Risk Residents With Pressure Ulcers
16.7%
3.7%
3.6%
5.6%
Q1 2015Q2 2015Q3 2015WI
Have Depressive Symptoms
1.7%
7.3%
12.1%
4.5%
Q1 2015Q2 2015Q3 2015WI
With a Urinary Tract Infection
0.0%
1.8%
3.4%
3.1%
Q1 2015Q2 2015Q3 2015WI
Experiencing One or More Falls with Major Injury
2.2%
1.6%
4.7%
3.9%
Q1 2015Q2 2015Q3 2015WI
With a Catheter Inserted and Left in Their Bladder
1.6%
0.0%
5.1%
0.4%
Q1 2015Q2 2015Q3 2015WI
Were Physically Restrained

Quality Measures for Short Stay Residents

98.4%
99.2%
100.0%
89.6%
Q1 2015Q2 2015Q3 2015WI
Assessed and Appropriately Given the Pneumococcal Vaccine
99.2%
98.4%
98.4%
88.4%
Q1 2015Q2 2015Q3 2015WI
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
25.7%
27.0%
33.3%
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
0.0%
0.0%
0.0%
1.0%
Q1 2015Q2 2015Q3 2015WI
With Pressure Ulcers That Are New or Worsened