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Cedar Springs Hlth Rehab Ctr

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About Cedar Springs Hlth Rehab Ctr

General Information

Legal Business NameFmg Lincoln Boulevard Wisconsin LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareJuly 27, 1995 (22 years)
Capacity78
Residents57
Percent Occupied73%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsResident
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Cedar Springs Hlth Rehab Ctr

Cedar Springs Hlth Rehab Ctr
was reviewed by Medicare to have a rating of 2 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

December 1, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$161,250 fine
---Payment DenialPayment denial for 31 days
LManyImmediate JeopardyHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
LManyImmediate JeopardyHealth InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
JFewImmediate JeopardyComplaint+InspectionGive each resident enough fluids to keep them healthy and prevent dehydration.
JFewImmediate JeopardyComplaint+InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
FManyPotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
FManyPotential for HarmComplaint+InspectionDevelop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property.
FManyPotential for HarmComplaint+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.
FManyPotential for HarmHealth Inspection1) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.
ESomePotential for HarmComplaint+InspectionProvide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
ESomePotential for HarmComplaint+InspectionTry to resolve each resident's complaints quickly.
ESomePotential for HarmHealth InspectionMake sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
ESomePotential for HarmHealth InspectionKeep residents' personal and medical records private and confidential.
CManyPotential for Minimal HarmHealth InspectionKeep clinical record information safe.
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.
DFewPotential for HarmComplaint+InspectionReasonably accommodate the needs and preferences of each resident.
DFewPotential for HarmComplaint+InspectionKeep accurate, complete and organized clinical records on each resident that meet professional standards.
DFewPotential for HarmHealth InspectionPrepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.
DFewPotential for HarmHealth InspectionConduct initial and periodic assessments of each resident's functional capacity.
DFewPotential for HarmHealth InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmHealth InspectionGive residents a notice of rights, rules, services and charges.
DFewPotential for HarmHealth InspectionLet residents refuse treatment, refuse to take part in an experiment, or formulate advance directives.
DFewPotential for HarmHealth InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmHealth InspectionProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmHealth InspectionEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential 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 InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.
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.

August 29, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintKeep accurate, complete and organized clinical records on each resident that meet professional standards.

April 29, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaintProvide housekeeping and maintenance services.
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintProvide care by qualified persons according to each resident's written plan of care.
DFewPotential for HarmComplaintGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

February 16, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaint1) 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 14, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmHealth Inspection1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day.
DFewPotential for HarmComplaintDevelop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home.
DFewPotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
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 InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Cedar Springs Hlth Rehab Ctr 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 15min
2hr 40min
ReportedExpected
CNA
40min
40min
ReportedExpected
LPN
1hr 40min
1hr 10min
ReportedExpected
RN
5hr 35min
4hr 30min
ReportedExpected
Total Nursing

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

Quality Measures for Long Stay Residents

100.0%
90.0%
90.0%
90.0%
96.9%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
91.2%
94.1%
100.0%
91.4%
97.5%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
-
-
-
-
46.5%
Q4 2015Q1 2016Q2 2016Q3 2016WI
* The data for this facility for some quarters is unavailable.
Percentage of low risk long-stay residents who lose control of their bowels or bladder
29.0%
28.1%
18.5%
15.6%
19.5%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents who received an antianxiety or hypnotic medication
26.7%
22.6%
16.9%
14.9%
17.7%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents whose ability to move independently worsened
13.3%
12.9%
3.6%
12.1%
12.7%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents who received an antipsychotic medication
20.0%
6.5%
4.0%
3.4%
14.0%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents whose need for help with daily activities has increased
4.7%
3.3%
0.0%
8.6%
8.7%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents who self-report moderate to severe pain
7.1%
11.8%
10.7%
5.9%
7.4%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents who lose too much weight
10.3%
12.1%
7.7%
3.3%
4.4%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of high risk long-stay residents with pressure ulcers
3.6%
10.7%
3.7%
3.0%
5.5%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents who have depressive symptoms
0.0%
11.8%
7.1%
8.8%
4.1%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents with a urinary tract infection
0.0%
5.9%
3.4%
2.9%
3.4%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents experiencing one or more falls with major injury
9.5%
7.5%
6.1%
6.4%
3.4%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.3%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

91.7%
85.3%
87.1%
87.6%
89.2%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
91.2%
78.4%
78.4%
78.4%
86.1%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
50.2%
39.8%
50.4%
54.9%
73.0%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of short-stay residents who made improvements in function
21.4%
14.1%
10.0%
16.0%
19.9%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of short-stay residents who self-report moderate to severe pain
0.9%
1.2%
2.0%
0.0%
1.2%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
0.8%
1.1%
0.9%
1.0%
Q4 2015Q1 2016Q2 2016Q3 2016WI
Percentage of short-stay residents with pressure ulcers that are new or worsened