mds 2.0 assessments completed fiscal 2018 q1 thru 2019 q4...mds 2.0 assessments completed ‐ by...

Minimum Data Set (MDS) 2.0 ‐ Quarterly Quality Report of 13

MDS 2.0 Assessments Completed ‐ Winnipeg

Assessed Not Assessed Assessed Not Assessed Assessed Not Assessed Assessed Not Assessed Assessed Not Assessed Assessed Not Assessed Assessed Not Assessed Assessed Not Assessed

5,635 602 5,618 566 5,645 619 5,559 711 5,566 745 5,625 750 5,768 811 5,658 962

FacilityNot

Assessed

Not

Assessed

Not

Assessed

Not

AssessedAssessed

Not

Assessed

Actionmarguerite (St. Boniface) 34 30 22 30 90.8% 9.2%

Actionmarguerite (St. Vital) 14 10 13 15 92.1% 7.9%

Actionmarguerite (St. Joseph's) 9 8 8 2 93.8% 6.2%

Bethania ‐ Bethania Mennonite PCH 11 7 17 7 93.5% 6.5%

Bethania ‐ Pembina Place Mennonite PCH 9 4 6 7 90.0% 10.0%

Concordia Place 21 25 15 16 88.0% 12.0%

Deer Ldg Ctr (60699) 22 18 15 16 92.2% 7.8%

Deer Ldg Ctr ‐ CC (63019) 10 7 7 7 93.2% 6.8%

Donwood Mnr PCH 6 8 7 9 94.3% 5.7%

Extendicare MB ‐ Oakview Place 19 23 9 12 94.0% 6.0%

Extendicare MB ‐ Tuxedo Villa 42 32 16 17 88.5% 11.5%

Extendicare MB ‐ Vista Park Lodge 13 9 7 18 89.6% 10.4%

Fred Douglas Lodge 16 14 10 8 91.8% 8.2%

Golden Door Geriatric Ctr 7 8 7 6 91.8% 8.2%

Golden Links Lodge 21 15 14 16 84.1% 15.9%

Holy Family NH 27 14 16 12 94.1% 5.9%

Lions PCCtr 7 3 3 5 96.3% 3.7%

Luther Hm 4 5 4 8 93.8% 6.2%

Meadowood Mnr 23 25 14 20 81.4% 18.6%

Misericordia HCtr ‐ Misericordia Place 3 6 9 9 93.8% 6.2%

Park Mnr PCH 8 5 6 11 92.9% 7.1%

Revera MB ‐ Beacon Hill Ldg 10 9 12 9 94.2% 5.8%

Revera MB ‐ Charleswood CCtr 33 21 25 19 85.0% 15.0%

Revera MB ‐ Heritage Ldg 31 18 26 13 77.7% 22.3%

Revera MB ‐ Kildonan PCC 21 14 12 11 89.4% 10.6%

Revera MB ‐ Maples PCH 14 14 13 20 93.1% 6.9%

Revera MB ‐ Parkview Place 25 20 17 20 90.7% 9.3%

Revera MB ‐ Poseidon CCtr 20 25 20 27 89.5% 10.5%

River East PCH 8 5 3 9 95.2% 4.8%

River Park Gardens 9 7 7 8 91.5% 8.5%

Riverview ‐ CC 8 12 9 5 85.2% 14.8%

Riverview ‐ PCH 13 17 10 18 94.4% 5.6%

Saul and Claribel Simkin Centre 15 14 10 6 94.7% 5.3%

Southeast Personal Care Home 6 8 6 8 92.0% 8.0%

St Norbert PCH 17 12 11 14 86.4% 13.6%

The Convalescent Hm Of Winnipeg 9 6 10 3 91.6% 8.4%

The Middlechurch Hm Of Winnipeg 13 14 41 40 87.5% 12.5%

The Salvation Army Golden West Cent Lodge 10 5 5 3 95.4% 4.6%

West Park Mnr PCH 31 27 26 24 84.3% 15.7%

Total 619 524 488 508 90.7% 9.3%

Fiscal 2018 Q1 Thru 2019 Q4

MDS 2.0 Assessments Completed ‐ by Winnipeg Facility

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

Definition: Residents assessed using the interRAI MDS 2.0 assessment instrument.

Note: Reasons for a resident not assessed can include the death, discharge or transfer of the resident

to another facility; in addition to missing or incomplete assessments.

282 290 294 284

150 153 148 153

150 152 151 149

200 204 216 221

107 108 109 104

55 60 60 58

246 247 252 250

203 203 213 206

2019 Q2

Assessed

2019 Q3

Assessed Assessed

2019 Q4

Assessed

2019 Q1

123 125 126 125

138 143 144 139

84 80 76 75

85 90 86 88

99 102 104 102

139 137 126 133

81 79 81 79

91 89 89 89

270 282 276 276

117 119 118 121

98 99 98 100

160 165 165 159

104 102 100 100

126 121 120 124

205 208 203 208

127 146 140 143

72 79 71 85

122 121 121

85 85 82 82

195 198 203 207

207 203 189 188

80 76 73

202 203 200 202

101 102 102 103

78 83 84 77

46 47 46 57

241 246 240 242

127

Wednesday, August 12, 2020Data Source: Canadian Institute for Health Information (CIHI) Continuing Care Reporting System (CCRS)

% Average

148 146 142 145

5,415 5,500 5,435 5,460

194 199 179 187

118 117 119 119

84 86 86 86

77

MDS 2.0 Assessments Completed

5,635 5,618 5,645 5,559 5,566 5,625 5,768 5,658

602 566 619 711 745 750 811 962

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

WRHA Long Term Care Program


Excludes: Respite and intake data (i.e. MDS Admission Assessments).

Type: Prevalence Indicator

Adjusted Rate:

Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted

7.9% 10.3% 7.7% 10.0% 7.2% 9.4% 6.4% 8.5% 5.6% 7.4% 4.7% 6.3% 4.1% 5.5% 3.8% 5.1%

Facility Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted

Actionmarguerite (St. Boniface) 5.3% 6.3% 3.7% 4.4% 1.9% 2.3% 1.6% 2.0%

Actionmarguerite (St. Vital) 3.1% 3.4% 0.4% 0.5% 0.4% 0.7% 0.4% 0.8%

Actionmarguerite (St. Joseph's) 5.1% 4.9% 3.8% 4.3% 2.7% 3.0% 2.7% 3.2%

Bethania ‐ Bethania Mennonite PCH 1.3% 1.9% 1.8% 2.3% 2.1% 2.8% 2.5% 3.3%

Bethania ‐ Pembina Place Mennonite PCH 0.0% 0.0% 0.5% 0.4% 0.5% 0.4% 1.0% 0.7%

Calvary Place PCH 6.4% 11.5% 5.2% 9.8% 4.0% 7.9% 2.7% 5.0%

Concordia Place 7.8% 7.9% 5.4% 5.4% 6.1% 5.9% 6.5% 6.3%

Deer Ldg Ctr (60699) 22.5% 28.1% 19.0% 24.1% 15.2% 19.8% 10.8% 14.8%

Donwood Mnr PCH 3.6% 4.6% 2.4% 3.5% 1.8% 2.6% 2.0% 2.9%

Extendicare MB ‐ Oakview Place 0.6% 0.4% 0.6% 0.7% 0.3% 0.6% 0.2% 0.7%

Extendicare MB ‐ Tuxedo Villa 1.1% 1.9% 0.8% 1.7% 0.3% 0.2% 0.1% 0.1%

Extendicare MB ‐ Vista Park Lodge 1.9% 1.5% 1.6% 1.5% 1.4% 1.4% 0.8% 1.2%

Fred Douglas Lodge 19.5% 19.4% 16.0% 16.2% 13.6% 13.7% 12.9% 13.1%

Golden Door Geriatric Ctr 2.2% 4.1% 1.8% 4.1% 1.1% 2.6% 0.4% 0.9%

Golden Links Lodge 8.8% 10.3% 7.5% 9.3% 7.2% 9.1% 6.6% 8.7%

Holy Family NH 3.7% 4.1% 3.9% 4.5% 4.0% 4.8% 4.2% 4.7%

Lions PCCtr 5.4% 6.8% 3.8% 5.4% 2.9% 4.1% 3.2% 4.7%

Luther Hm 9.2% 10.0% 7.7% 8.7% 8.3% 9.5% 8.6% 9.6%

Meadowood Mnr 4.3% 5.6% 4.1% 5.1% 4.1% 5.1% 3.9% 4.9%

Misericordia HCtr ‐ Misericordia Place 13.6% 15.2% 9.5% 10.5% 6.4% 6.8% 6.0% 6.4%

Park Mnr PCH 2.2% 2.6% 3.0% 3.7% 3.0% 3.7% 3.0% 3.4%

Revera MB ‐ Beacon Hill Ldg 3.1% 6.0% 2.7% 5.2% 2.0% 3.9% 1.8% 3.5%

Revera MB ‐ Charleswood CCtr 0.6% 1.8% 0.2% 0.1% 0.4% 1.1% 0.6% 0.9%

Revera MB ‐ Heritage Ldg 4.4% 6.1% 4.1% 4.7% 4.5% 5.1% 4.1% 3.3%

Revera MB ‐ Kildonan PCC 0.5% 0.6% 0.2% 0.2% 0.7% 1.1% 1.1% 2.2%

Revera MB ‐ Maples PCH 0.8% 1.0% 0.6% 0.9% 0.6% 1.2% 0.9% 1.8%

Revera MB ‐ Parkview Place 2.1% 3.0% 1.9% 2.7% 2.0% 3.2% 2.0% 5.6%

Revera MB ‐ Poseidon CCtr 0.7% 0.4% 0.9% 2.2% 1.0% 3.4% 0.8% 2.8%

River East PCH 2.3% 3.6% 2.3% 3.9% 1.8% 3.9% 0.9% 2.7%

River Park Gardens 1.4% 2.2% 1.0% 1.6% 1.0% 1.5% 1.3% 1.8%

Riverview ‐ PCH 12.3% 15.5% 11.5% 14.3% 10.8% 13.3% 9.8% 11.9%

Saul and Claribel Simkin Centre 3.8% 5.6% 3.0% 4.3% 2.6% 3.8% 3.0% 4.4%

Southeast Personal Care Home 6.2% 6.9% 2.4% 3.2% 2.4% 3.7% 3.2% 5.1%

St Norbert PCH 3.8% 5.2% 4.1% 4.9% 3.4% 3.7% 3.1% 2.6%

The Convalescent Hm Of Winnipeg 22.0% 27.0% 23.6% 29.3% 20.9% 26.2% 17.4% 21.5%

The Middlechurch Hm Of Winnipeg 7.1% 8.6% 7.0% 8.5% 6.3% 7.6% 6.0% 7.4%

32 The Salvation Army Golden West Cent Lodge 4.6% 4.9% 1.9% 1.8% 1.6% 1.9% 3.4% 4.1%

West Park Mnr PCH 10.7% 12.7% 10.4% 12.2% 10.4% 12.4% 10.5% 12.8%

Percent of residents with pain

Fiscal 2018 Q1 thru 2019 Q4

Variables considered in this calculation include residents' cognitive performance, long term memory problems, and age.

2018 Q1 thru 2019 Q4

Adjusted

Previous Four Quarters

Unadjusted

Winnipeg Winnipeg Winnipeg

2019 Q1 2019 Q2 2019 Q3 2019 Q4

Winnipeg

Personal Care Homes in Winnipeg

Winnipeg Winnipeg Winnipeg

Lower percentages are more desireable

Direction Previous Eight Quarters

Winnipeg

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

Average of Personal Care Homes in

Winnipeg (Non Chronic Care)

Residents with moderate pain at least daily or horrible/excruciating pain at any frequency.Definition:

Data Source: Canadian Institute for Health Information (CIHI) Continuing Care Reporting System (CCRS) Wednesday, August 12, 2020

7.9% 7.7% 7.2% 6.4% 5.6% 4.7% 4.1% 3.8%

10.3% 10.0% 9.4% 8.5% 7.4% 6.3% 5.5% 5.1%0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

7.1% 7.0% 6.8% 6.7% 6.5% 6.4% 6.3% 6.2%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4


PositiveNegative Neutral

Canadian Adjusted Rate Winnipeg Adjusted Rate

Winnipeg Unadjusted Rate



Type: Incidence Indicator

Adjusted Rate:


5.2% 5.8% 5.0% 5.6% 4.5% 4.9% 4.2% 4.5% 3.9% 4.2% 4.0% 4.2% 4.2% 4.5% 4.3% 4.6%








Concordia Place 4.2% 3.7% 4.0% 3.8% 4.0% 3.7% 5.3% 4.9%

Deer Ldg Ctr (60699) 6.7% 6.8% 5.5% 5.5% 4.5% 4.1% 3.9% 3.5%

Donwood Mnr PCH 3.9% 4.2% 3.2% 3.7% 2.7% 3.2% 3.1% 3.4%







Holy Family NH 3.0% 3.3% 2.8% 2.8% 2.8% 3.9% 4.1% 5.3%

Lions PCCtr 3.3% 2.7% 2.3% 2.3% 2.1% 2.2% 3.1% 3.6%

Luther Hm 2.4% 1.9% 3.1% 2.4% 4.4% 3.5% 4.7% 4.3%

Meadowood Mnr 2.9% 3.1% 3.5% 3.7% 4.5% 5.3% 5.2% 5.6%


Park Mnr PCH 1.9% 2.3% 3.0% 3.8% 3.3% 4.2% 3.6% 4.2%








River East PCH 3.1% 5.1% 5.2% 7.3% 6.0% 8.1% 4.8% 6.1%


Riverview ‐ PCH 3.1% 2.9% 2.2% 2.0% 1.8% 1.8% 1.9% 1.8%



St Norbert PCH 2.1% 3.9% 3.1% 4.2% 4.6% 5.0% 5.2% 6.7%



The Salvation Army Golden West Cent Lodge 6.7% 6.7% 5.2% 5.0% 5.2% 4.7% 6.7% 6.5%

West Park Mnr PCH 2.0% 1.7% 2.3% 2.0% 2.3% 2.0% 3.3% 3.3%

Percent of residents whose pain worsened


Definition: Residents whose pain worsened during the 90 day period, as measured by the interRAI Pain Scale.

The scale captures both frequency and intensity of pain.


Winnipeg (Non Chronic Care)Variable considered in this calculation is residents' age.

2019 Q3 2019 Q4

Winnipeg Winnipeg Winnipeg Winnipeg Winnipeg Winnipeg Winnipeg Winnipeg

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2

Personal Care Homes in WinnipegDirection Previous Eight Quarters


Lower percentages are more desireable 2019 Q1 2019 Q2 2019 Q3 2019 Q4 2017 Q4 thru 2019 Q3

Unadjusted Adjusted


5.2% 5.0% 4.5% 4.2% 3.9% 4.0% 4.2% 4.3%5.8% 5.6% 4.9% 4.5% 4.2% 4.2% 4.5% 4.6%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

10.2% 10.2% 10.1% 10.1% 10.0% 10.1% 10.1% 10.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4








Adjusted Rate:


18.3% 19.7% 18.2% 19.6% 18.2% 19.8% 18.4% 20.1% 18.7% 20.5% 19.0% 20.8% 19.1% 20.9% 19.1% 20.9%








Concordia Place 18.3% 22.4% 19.2% 23.4% 19.4% 23.4% 19.3% 22.6%

Deer Ldg Ctr (60699) 34.6% 31.9% 32.5% 31.3% 31.0% 30.8% 30.1% 30.3%

Donwood Mnr PCH 13.3% 12.7% 12.0% 12.0% 11.6% 11.9% 11.8% 13.2%







Holy Family NH 20.9% 26.0% 20.8% 24.3% 21.2% 23.7% 21.6% 24.2%

Lions PCCtr 2.7% 5.3% 3.0% 6.1% 2.6% 6.7% 2.5% 5.2%

Luther Hm 12.7% 19.6% 12.9% 19.2% 13.3% 18.6% 14.0% 19.3%

Meadowood Mnr 18.0% 18.0% 18.4% 18.8% 18.9% 20.6% 18.8% 21.8%


Park Mnr PCH 19.8% 21.2% 18.9% 20.5% 18.3% 19.7% 17.3% 19.2%








River East PCH 11.6% 12.4% 12.9% 12.4% 16.2% 14.3% 19.8% 16.8%


Riverview ‐ PCH 31.0% 28.7% 32.3% 29.5% 32.9% 29.8% 33.6% 30.4%



St Norbert PCH 20.3% 22.6% 19.3% 22.0% 18.1% 22.6% 16.5% 22.1%




West Park Mnr PCH 14.3% 13.5% 14.4% 13.7% 15.0% 14.6% 15.0% 14.9%

Percent of residents on antipsychotics without a diagnosis of psychosis


Definition: Residents who received an antipsychotic medication during the previous 90 days who did not have schizophrenia,

Huntingon's syndrome, or hallucinations recorded on their MDS Assessment.


Winnipeg (Non Chronic Care)Variables considered in this calculation include motor agitation, moderate/impaired decision making, long‐term memory problem,

cognitive performance, and combination Alzheimer's.

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


18.3% 18.2% 18.2% 18.4% 18.7% 19.0% 19.1% 19.1%19.7% 19.6% 19.8% 20.1% 20.5% 20.8% 20.9% 20.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

21.2% 21.0% 20.9% 20.7% 20.5% 20.4% 20.3% 20.2%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4








Adjusted Rate:


5.6% 6.0% 5.7% 6.2% 5.7% 6.2% 5.9% 6.3% 5.7% 6.1% 5.6% 6.0% 5.6% 6.0% 5.6% 6.0%








Concordia Place 4.2% 4.5% 4.7% 5.1% 5.4% 5.9% 4.6% 5.1%

Deer Ldg Ctr (60699) 5.0% 4.7% 5.0% 4.3% 4.6% 4.0% 5.1% 4.1%

Donwood Mnr PCH 6.2% 4.8% 7.1% 5.1% 6.9% 6.0% 6.8% 6.2%







Holy Family NH 1.7% 1.9% 2.5% 2.7% 2.7% 2.8% 3.5% 3.6%

Lions PCCtr 4.0% 4.5% 4.4% 4.9% 5.5% 6.1% 4.3% 4.8%

Luther Hm 3.8% 4.3% 5.7% 6.7% 5.4% 6.6% 5.3% 7.0%

Meadowood Mnr 4.1% 4.4% 3.5% 3.7% 3.9% 4.4% 4.6% 5.4%


Park Mnr PCH 6.5% 7.1% 6.0% 6.7% 5.5% 6.1% 5.3% 5.8%








River East PCH 11.8% 13.7% 11.5% 13.1% 10.7% 11.6% 7.0% 7.3%


Riverview ‐ PCH 4.9% 5.2% 5.3% 5.8% 5.0% 5.4% 3.9% 4.1%



St Norbert PCH 2.9% 3.6% 2.9% 3.3% 3.8% 4.3% 4.4% 5.2%




West Park Mnr PCH 3.1% 3.3% 2.7% 2.9% 3.0% 3.1% 4.0% 4.1%

Percent of residents whose behavioural symptoms worsened


Definition: Residents whose behaviour symptoms worsened during the 90 day period, as measured by the number of difficult behaviours

documented on the MDS assessment (i.e., wandering, verbal/phyisically abusive, socially inappropriate.


Winnipeg (Non Chronic Care)Variables considered in this calculation include moderate/impaired decision‐making, motor agitation, cognitive performance, and

age of residents.

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


5.6% 5.7% 5.7% 5.9% 5.7% 5.6% 5.6% 5.6%6.0% 6.2% 6.2% 6.3% 6.1% 6.0% 6.0% 6.0%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

12.3% 12.3% 12.3% 12.3% 12.3% 12.4% 12.4% 12.4%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4








Adjusted Rate:


9.7% 10.2% 9.6% 10.1% 9.6% 10.1% 9.6% 10.1% 9.6% 10.1% 9.6% 10.0% 9.4% 9.9% 9.2% 9.7%








Concordia Place 7.6% 10.8% 7.4% 10.5% 7.1% 10.0% 6.3% 8.5%

Deer Ldg Ctr (60699) 11.1% 15.5% 11.4% 15.6% 12.0% 16.2% 12.6% 16.9%

Donwood Mnr PCH 10.0% 8.1% 10.2% 8.5% 10.3% 8.4% 10.1% 8.0%







Holy Family NH 28.3% 34.6% 27.5% 34.0% 26.4% 32.7% 25.2% 32.0%

Lions PCCtr 0.2% 0.3% 0.7% 0.9% 1.2% 1.4% 2.0% 2.3%

Luther Hm 4.7% 7.9% 4.4% 7.6% 3.7% 6.3% 3.3% 5.5%

Meadowood Mnr 7.4% 6.4% 6.0% 5.7% 6.0% 6.3% 6.1% 6.8%


Park Mnr PCH 6.0% 3.5% 6.3% 3.7% 6.1% 3.8% 6.1% 3.9%








River East PCH 2.7% 3.4% 2.5% 3.1% 1.4% 1.7% 1.6% 1.9%


Riverview ‐ PCH 17.3% 20.5% 18.4% 21.3% 19.6% 22.2% 20.7% 23.2%



St Norbert PCH 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%




West Park Mnr PCH 4.9% 5.6% 4.3% 4.7% 5.2% 5.4% 8.4% 8.7%

Percent of residents in daily physical restraints


Definition:Residents who were physicially restrained during the 90 day period as documented on the MDS assessment.


Winnipeg (Non Chronic Care)Variables considered in this calculation include residents' scores in relation to the Activities of Daily Living (ADL) long form scale.

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


9.7% 9.6% 9.6% 9.6% 9.6% 9.6% 9.4% 9.2%10.2% 10.1%

10.1% 10.1% 10.1%10.0% 9.9% 9.7%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

5.6% 5.5% 5.3% 5.2% 5.1% 5.0% 4.8% 4.6%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4








Adjusted Rate:


13.8% 17.0% 14.1% 17.4% 13.9% 17.5% 13.9% 17.5% 14.0% 17.7% 13.7% 17.4% 13.5% 17.2% 13.2% 16.8%








Concordia Place 14.0% 18.0% 13.4% 16.9% 13.5% 17.1% 13.9% 16.8%

Deer Ldg Ctr (60699) 18.2% 17.8% 16.8% 15.7% 17.2% 16.0% 17.4% 16.5%

Donwood Mnr PCH 18.0% 27.7% 15.1% 23.1% 13.2% 22.4% 11.9% 17.6%







Holy Family NH 8.3% 8.7% 8.2% 9.1% 8.5% 9.6% 9.6% 11.5%

Lions PCCtr 10.6% 10.6% 11.4% 11.8% 13.0% 15.1% 15.3% 19.7%

Luther Hm 15.3% 15.5% 14.8% 15.4% 15.7% 15.9% 13.9% 14.6%

Meadowood Mnr 13.6% 14.9% 15.1% 15.6% 15.2% 15.4% 14.1% 14.2%


Park Mnr PCH 16.0% 22.2% 15.3% 22.9% 13.8% 20.6% 11.6% 17.1%








River East PCH 18.9% 23.8% 16.9% 22.1% 17.2% 23.7% 13.9% 21.1%


Riverview ‐ PCH 11.8% 15.1% 10.6% 14.7% 10.0% 13.6% 10.1% 13.7%



St Norbert PCH 21.0% 29.5% 22.4% 31.9% 21.5% 33.0% 21.6% 29.7%




West Park Mnr PCH 17.5% 19.0% 18.3% 20.4% 17.9% 21.0% 15.5% 17.8%

Percent of residents who fell in the last 30 days


Definition:Residents who had a fall in the last 30 days, as recorded on their MDS assessment.


Winnipeg (Non Chronic Care)Variables considered in this calculation include residents' ability to transfer, locomotion, wandering, unsteady gait, cogitive

impairment, personal severity index and age.

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


13.8% 14.1% 13.9% 13.9% 14.0% 13.7% 13.5% 13.2%

17.0% 17.4% 17.5% 17.5% 17.7% 17.4% 17.2% 16.8%

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

20.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

16.4% 16.6% 16.7% 16.7% 16.7% 16.7% 16.7% 16.7%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4






Excludes: None: Report includes all residents with a valid assessment (e.g. Admission, Full, Quarterly, etc) completed in the last 90 days


Adjusted Rate:


3.8% 8.9% 3.6% 8.8% 3.4% 8.6% 3.3% 8.3% 3.3% 8.3% 3.4% 8.4% 3.4% 8.5% 3.4% 8.7%








Concordia Place 4.3% 9.3% 4.5% 9.8% 4.8% 10.1% 4.6% 10.9%

Deer Ldg Ctr (60699) 3.8% 6.9% 3.2% 5.8% 2.8% 5.6% 2.9% 6.1%

Donwood Mnr PCH 2.9% 5.1% 2.7% 4.8% 2.2% 3.8% 2.9% 5.8%







Holy Family NH 5.4% 10.7% 5.5% 10.7% 5.4% 10.1% 5.7% 11.5%

Lions PCCtr 1.2% 1.6% 1.7% 2.3% 2.2% 3.3% 2.7% 4.6%

Luther Hm 4.1% 9.3% 3.7% 8.7% 4.7% 11.0% 4.3% 10.4%

Meadowood Mnr 6.8% 14.9% 5.7% 13.8% 5.7% 14.7% 5.1% 14.0%


Park Mnr PCH 2.2% 7.5% 2.2% 6.5% 2.5% 5.7% 2.8% 4.5%








River East PCH 4.3% 9.3% 4.6% 10.2% 4.5% 10.4% 4.7% 12.6%


Riverview ‐ PCH 2.5% 6.6% 2.6% 6.5% 2.7% 6.9% 2.6% 6.8%



St Norbert PCH 1.6% 6.8% 1.9% 6.3% 1.2% 3.2% 0.9% 1.6%




West Park Mnr PCH 5.6% 12.4% 5.5% 12.2% 5.0% 11.0% 4.5% 10.6%

Percent of residents that have a stage 2 to 4 pressure ulcer


Definition: Percent of residents who had a stage 2 to 4 pressure ulcer

Numerator: Residents who had a pressure ulcer at stages 2 to 4 on their target MDS assessment


Winnipeg (Non Chronic Care)Variables considered in this calculation include RUG Cognitive Impairment; PSI Subset 1 Diagnoses More dependence in toileting;

Age younger than 65

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


3.8% 3.6% 3.4% 3.3% 3.3%3.4% 3.4% 3.4%

8.9% 8.8% 8.6% 8.3% 8.3% 8.4% 8.5% 8.7%

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

5.7% 5.7% 5.6% 5.6% 5.6% 5.5% 5.5% 5.4%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4








Adjusted Rate:


1.7% 2.5% 1.6% 2.4% 1.5% 2.4% 1.5% 2.4% 1.5% 2.4% 1.6% 2.5% 1.6% 2.5% 1.6% 2.5%








Concordia Place 1.6% 2.3% 1.6% 2.5% 1.6% 2.6% 1.2% 2.0%

Deer Ldg Ctr (60699) 1.4% 2.3% 0.9% 1.3% 0.9% 1.5% 1.0% 1.6%

Donwood Mnr PCH 1.8% 2.1% 1.6% 1.9% 1.1% 1.4% 1.8% 2.5%







Holy Family NH 2.8% 4.7% 2.5% 4.2% 2.3% 4.0% 2.5% 5.5%

Lions PCCtr 1.0% 1.1% 1.3% 1.4% 1.6% 1.6% 1.9% 2.0%

Luther Hm 1.8% 1.8% 1.4% 1.5% 2.4% 2.9% 2.1% 2.7%

Meadowood Mnr 1.7% 2.2% 0.7% 1.2% 1.4% 3.2% 1.0% 2.6%


Park Mnr PCH 0.8% 1.8% 1.1% 2.3% 1.7% 2.4% 2.0% 1.8%








River East PCH 2.1% 3.4% 2.6% 4.9% 3.1% 5.8% 3.1% 6.8%


Riverview ‐ PCH 0.5% 0.7% 0.6% 0.8% 0.8% 1.2% 1.0% 1.6%



St Norbert PCH 1.0% 2.7% 1.3% 2.9% 1.0% 1.8% 0.6% 0.6%




West Park Mnr PCH 1.4% 3.7% 1.2% 3.7% 1.2% 3.3% 1.4% 3.4%

Percent of residents with a newly occurring stage 2 to 4 pressure ulcer


Definition: Residents who had a pressure ulcer at stages 2 to 4 on their MDS assessment (in the last 90 days) and no pressure ulcer at stages

2 to 4 on their prior assessment.


Winnipeg (Non Chronic Care)Variables considered in this calculation include residents' age, personal serverity index, toileting dependence and cognitive

impairment.

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


1.7% 1.6% 1.5% 1.5% 1.5% 1.6% 1.6% 1.6%

2.5% 2.4% 2.4% 2.4% 2.4% 2.5% 2.5% 2.5%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

2.3% 2.3%2.3% 2.2% 2.2% 2.2% 2.2% 2.2%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4








Adjusted Rate:


1.7% 2.6% 1.6% 2.6% 1.6% 2.5% 1.6% 2.5% 1.6% 2.5% 1.7% 2.6% 1.6% 2.6% 1.6% 2.6%








Concordia Place 1.8% 2.8% 1.8% 3.0% 1.8% 3.0% 1.2% 1.9%

Deer Ldg Ctr (60699) 1.4% 2.1% 0.8% 1.2% 0.9% 1.4% 1.0% 1.5%

Donwood Mnr PCH 1.8% 2.2% 1.6% 2.0% 1.1% 1.6% 1.8% 2.8%







Holy Family NH 2.7% 4.8% 2.5% 4.5% 2.3% 4.5% 2.4% 5.9%

Lions PCCtr 1.0% 1.4% 1.3% 1.6% 1.6% 1.9% 1.9% 2.2%

Luther Hm 1.7% 1.4% 1.7% 1.5% 2.7% 2.6% 2.3% 2.4%

Meadowood Mnr 1.6% 1.7% 0.6% 0.8% 1.3% 2.3% 1.0% 1.8%


Park Mnr PCH 0.8% 1.9% 1.1% 2.6% 1.7% 2.7% 2.0% 1.8%








River East PCH 2.3% 4.3% 2.8% 6.2% 3.2% 6.7% 3.2% 8.2%


Riverview ‐ PCH 0.5% 0.6% 0.7% 1.0% 0.9% 1.4% 1.1% 1.7%



St Norbert PCH 1.3% 3.7% 1.3% 3.1% 1.0% 1.9% 0.6% 0.5%




West Park Mnr PCH 1.3% 2.5% 1.1% 2.4% 1.1% 2.3% 1.3% 2.5%

Percent of residents whose stage 2 to 4 pressure ulcer worsened


Definition: Residents whose stage 2 to 4 pressure ulcer worsened. Residents who had a pressure ulcer at

stages 2 to 4 on their MDS assessment that is greater when compared with their prior assessment.


Winnipeg (Non Chronic Care)Variables considered in this calculation include residents' age and late loss Activities of Daily living (ADL).

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


1.7% 1.6% 1.6% 1.6% 1.6% 1.7% 1.6% 1.6%

2.6% 2.6% 2.5% 2.5% 2.5% 2.6% 2.6% 2.6%

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

3.0%

3.5%

4.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

2.8% 2.7% 2.7% 2.7% 2.7% 2.7% 2.7% 2.6%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4






Excludes: Respite and intake data (i.e. MDS Admission Assessments)


Adjusted Rate:


7.8% 7.8% 7.9% 8.0% 7.9% 8.0% 8.0% 8.1% 7.8% 7.9% 7.7% 7.8% 7.5% 7.7% 7.4% 7.6%








Concordia Place 8.7% 8.8% 9.1% 8.8% 8.5% 8.1% 7.4% 7.4%

Deer Ldg Ctr (60699) 6.3% 6.3% 6.9% 7.0% 7.7% 7.1% 7.4% 7.0%

Donwood Mnr PCH 15.1% 14.6% 14.5% 15.0% 10.2% 10.7% 8.6% 8.6%







Holy Family NH 1.7% 1.7% 2.4% 2.6% 2.7% 3.2% 3.3% 4.6%

Lions PCCtr 7.6% 6.9% 7.5% 7.3% 8.6% 8.8% 8.0% 9.4%

Luther Hm 4.8% 4.2% 5.7% 5.7% 5.4% 5.5% 6.7% 7.0%

Meadowood Mnr 8.5% 7.8% 10.6% 9.3% 9.8% 9.4% 9.0% 8.0%


Park Mnr PCH 5.7% 6.5% 5.2% 5.0% 6.1% 5.4% 8.6% 8.1%








River East PCH 16.4% 19.2% 17.2% 21.4% 14.8% 18.0% 12.0% 13.8%


Riverview ‐ PCH 4.4% 4.7% 5.0% 5.2% 5.8% 5.8% 4.8% 4.6%



St Norbert PCH 4.5% 4.7% 5.4% 5.5% 7.0% 8.1% 6.6% 7.5%




West Park Mnr PCH 5.2% 5.6% 5.0% 5.3% 4.3% 4.9% 4.2% 4.8%

Percent of residents whose mood from symptoms of depression worsened


Definition: Residents whose mood from symptoms of depression worsened, (i.e. Depression Rating Scale (DRS) score is higher in comparison

with score obtained on their prior MDS assessment.)


Winnipeg (Non Chronic Care)Variable considered in this calculation is residents' age.

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


7.8% 7.9% 7.9% 8.0% 7.8% 7.7% 7.5% 7.4%7.8% 8.0% 8.0% 8.1% 7.9% 7.8% 7.7% 7.6%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

21.6% 21.5% 21.5% 21.3% 21.1% 21.2% 21.2% 21.1%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4






Excludes: Excludes comatose and end‐of‐life residents.


Adjusted Rate:


30.3% 30.2% 30.3% 30.2% 30.0% 29.8% 30.1% 29.9% 30.2% 30.1% 30.4% 30.3% 30.6% 30.5% 30.5% 30.4%







Concordia Place 27.7% 22.3% 30.0% 24.5% 31.4% 26.2% 32.6% 27.7%

Deer Ldg Ctr (60699) 34.1% 28.4% 33.4% 28.6% 33.7% 29.9% 33.9% 30.7%

Donwood Mnr PCH 23.5% 28.2% 24.9% 28.8% 25.1% 28.9% 23.3% 26.9%







Holy Family NH 22.7% 20.4% 22.5% 19.7% 22.1% 19.0% 23.4% 19.6%

Lions PCCtr 49.0% 34.9% 47.8% 34.7% 47.5% 34.6% 44.3% 32.8%

Luther Hm 22.3% 21.8% 23.9% 23.0% 25.8% 25.1% 27.3% 26.4%

Meadowood Mnr 17.0% 20.5% 17.7% 20.5% 19.5% 21.7% 19.2% 21.1%


Park Mnr PCH 19.3% 32.9% 18.1% 30.5% 16.9% 26.6% 16.1% 24.8%








River East PCH 45.3% 41.2% 45.9% 41.6% 45.4% 41.0% 44.3% 38.6%


Riverview ‐ PCH 29.6% 26.8% 30.1% 28.1% 29.3% 28.3% 29.5% 29.4%



St Norbert PCH 30.7% 31.2% 29.7% 30.5% 27.9% 28.7% 28.2% 28.6%




West Park Mnr PCH 23.3% 24.3% 22.9% 24.3% 22.0% 24.0% 20.9% 23.2%

Percent of residents with improved physical functioning


Definition: Percent of residents whose mid‐loss ADL functioning (transfer and locomotion) improved or who remained completely

independent in mid‐loss ADLs.


Winnipeg (Non Chronic Care)Variable considered in the adjusted calculation include residents' age and cognitive performance scale (CPS) score.

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2



Higher percentages are more desireable 2019 Q1 2019 Q2 2019 Q3 2019 Q4 2018 Q1 thru 2019 Q4

Unadjusted Adjusted


30.3% 30.3% 30.0% 30.1% 30.2% 30.4% 30.6% 30.5%30.2% 30.2% 29.8% 29.9% 30.1% 30.3% 30.5% 30.4%

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

31.4% 31.3% 31.3% 31.4% 31.3% 31.3% 31.4% 31.3%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4






Excludes: Excludes comatose and end‐of‐life residents.


Adjusted Rate:


31.2% 27.1% 31.1% 26.9% 31.0% 26.7% 30.8% 26.5% 31.1% 26.6% 31.3% 26.7% 31.5% 26.9% 31.6% 27.0%








Concordia Place 22.5% 20.7% 22.9% 20.9% 24.1% 21.4% 24.4% 20.9%

Deer Ldg Ctr (60699) 16.9% 17.4% 17.0% 17.8% 18.4% 19.6% 18.5% 20.0%

Donwood Mnr PCH 43.0% 28.2% 41.4% 26.3% 43.3% 28.2% 42.8% 28.1%







Holy Family NH 24.4% 27.0% 24.9% 27.4% 24.5% 27.2% 25.0% 28.0%

Lions PCCtr 20.2% 23.3% 22.7% 25.1% 24.2% 25.8% 26.6% 30.9%

Luther Hm 17.8% 18.8% 19.5% 21.0% 19.8% 21.5% 21.3% 22.5%

Meadowood Mnr 30.3% 21.1% 29.0% 20.3% 27.9% 18.6% 26.5% 16.4%


Park Mnr PCH 45.8% 26.6% 46.0% 27.2% 45.9% 27.7% 44.4% 26.0%








River East PCH 33.3% 30.6% 35.3% 32.1% 37.6% 33.0% 36.6% 32.2%


Riverview ‐ PCH 24.0% 21.9% 24.9% 22.3% 25.9% 22.5% 24.8% 21.1%



St Norbert PCH 31.4% 26.5% 30.7% 25.6% 34.0% 27.2% 33.5% 27.5%




West Park Mnr PCH 27.5% 23.6% 27.7% 23.2% 28.0% 22.5% 29.4% 22.6%

Percent of residents with worsened physical functioning


Definition: Percent of residents whose mid‐loss ADL functioning (transfer and locomotion) worsened or who remained completely

dependent in mid‐loss ADLs.


Winnipeg (Non Chronic Care)Variables considered in the adjusted calculation include residents' age, locomotion problem and PSI subset 2: Non‐Diagnoses.

2019 Q3 2019 Q4


2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2




Unadjusted Adjusted


31.2% 31.1% 31.0% 30.8% 31.1% 31.3% 31.5% 31.6%27.1% 26.9% 26.7% 26.5% 26.6% 26.7% 26.9% 27.0%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4

33.1% 33.2% 33.2% 33.2% 33.2% 33.3% 33.3% 33.5%

2018 Q1 2018 Q2 2018 Q3 2018 Q4 2019 Q1 2019 Q2 2019 Q3 2019 Q4





mds 2.0 assessments completed fiscal 2018 q1 thru 2019 q4...mds 2.0 assessments completed ‐ by...

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