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Pepin Manor

Details

Type of Ownership For profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 50
Continuing Care? No
Resident Council? Yes
Family Council? No
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 04/06/2011

Date of last standard health inspection: 04/06/2011
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 1
Average number of Health Deficiencies in WI: 3
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in WI: 0 - 23
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/05/2012 01/04/2001 2 Few

Inspection, 00/07/2006

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 00/07/2006 00/07/2007 1 Many
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 00/07/2006 00/07/2007 2 Few
Have a program that investigates, controls and keeps infection from spreading. 00/07/2006 00/07/2007 2 Few
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide necessary care and services to maintain or improve the highest well being of each resident. 00/07/2006 00/07/2007 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that residents are fully informed and understand their health status, care and treatments. 00/07/2006 00/07/2007 2 Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. 00/07/2006 00/07/2007 2 Few

Inspection, 00/06/2004

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Operate and provide services according to Federal, State, and local laws and professional standards. 00/06/2004 00/06/2005 2 Few
Keep accurate, complete and organized clinical records on each resident that meet professional standards. 00/06/2004 00/06/2005 2 Few
Operate and provide services according to Federal 00/06/2004 00/06/2005 and local laws and professional standards. State
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Have a program that investigates, controls and keeps infection from spreading. 00/06/2004 00/06/2005 2 Some
Nutrition and Dietary Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. 00/06/2004 00/06/2005 1 Some
Prepare food that is nutritional 00/06/2004 00/06/2005 tasty appetizing
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Send unopened mail from residents and promptly deliver unopened mail to residents. 00/06/2004 00/06/2005 2 Few
Provide timely notification to the resident before transfer or discharge. 00/06/2004 00/06/2005 2 Some
Send unopened mail from residents and promptly deliver unopened mail to residents. 00/06/2004 00/06/2005 2 Few
Provide timely notification to the resident before transfer or discharge. 00/06/2004 00/06/2005 2 Some

Inspection, 03/01/2003

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Post nurse staffing information/data on a daily basis. 03/01/2003 00/01/2005 1 Many
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 03/01/2003 00/01/2005 2 Few
Dispose of garbage and refuse properly. 03/01/2003 00/01/2005 2 Few
Have a program that investigates, controls and keeps infection from spreading. 03/01/2003 00/01/2005 2 Few
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure 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. 03/01/2003 00/01/2005 2 Few
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 03/01/2003 00/01/2005 2 Few
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. 03/01/2003 00/01/2005 2 Few
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Conduct initial and periodic assessments of each resident's functional capacity. 03/01/2003 00/01/2005 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents a notice of rights, rules, services and charges. 03/01/2003 00/01/2005 1 Some
Allow residents to easily view the results of the nursing home's most recent inspection. 03/01/2003 00/01/2005 1 Many
Allow residents to self-administer drugs if determined safe. 03/01/2003 00/01/2005 2 Few

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in WI Golden Living Center, Asheville
RN Staff Only1 N/A N/A 4 out of 5 stars
Total Number of Residents 86 73 44
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 5 hours 45 minutes 1 hour 13 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 5 hours 12 minutes 42 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 4 hours 54 minutes 31 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 6 hours 51 minutes 1 hour 57 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 04/11/2011

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 04/11/2011
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in WI: 0
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in WI: 0 - 0

Inspection, 01/01/2004

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Back-up procedures in place for a faulty automatic sprinkler system. 01/01/2004 01/01/2005 1 Many
Fire Alarm Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved back-up procedure for a faulty fire alarm system. 01/01/2004 01/01/2005 1 Many

Inspection, 03/01/2003

Electrical Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Weekly inspections and monthly testing of generators. 03/01/2003 03/01/2007 2 Many
Properly installed electrical wiring and equipment. 03/01/2003 00/01/2005 2 Few
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 03/01/2003 00/01/2005 2 Some
 

1110 Second St
Pepin, WI 54759

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