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About Victoria Falls

General Information

Legal Business NameAndover Senior Care, LLC
Ownership TypeFor Profit - Corporation
Changed Ownership In The Last 12 MonthsNo
First Accepted MedicareMarch 25, 2011 (6 years)
Capacity76
Residents68
Percent Occupied89%
Program ParticipationMedicare And Medicaid
Resident And Family CouncilsBoth
In HospitalNo
Continuing Care Retirement CommunityNo
Special Focus FacilityNo
Auto Sprinkler System In Required AreasYes

Ratings for Victoria Falls

Victoria Falls
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 Kansas 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 9, 2015 - 14 months ago

 Residents AffectedSeveritySource/TypeDescription
JFewImmediate JeopardyComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintPrevent a loss in range of motion among residents who entered the nursing home with a full range of motion, unless it is unavoidable due to residentís clinical condition.
DFewPotential for HarmComplaintMake sure that each residents' abilities in activities of daily living do not decline, unless unavoidable.
DFewPotential for HarmComplaintImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

August 25, 2015 - 16 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.

May 15, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .
DFewPotential for HarmComplaintEnsure services provided by the nursing facility meet professional standards of quality.

April 24, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintEnsure that residents are safe from serious medication errors.
DFewPotential for HarmComplaintGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
DFewPotential for HarmComplaintEvaluate a residentís decrease in social interaction or increase in depressive behaviors and determine if the behavioral changes were avoidable if these problems did not exist before.
DFewPotential for HarmComplaintProtect each resident from all abuse, physical punishment, and involuntary separation from others.

April 7, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
FManyPotential for HarmFire Safety InspectionEmergency lighting that can last at least 1 1/2 hours.
FManyPotential for HarmFire Safety InspectionWalls that prevent smoke from passing through and would resist fire for at least one hour.
ESomePotential for HarmFire Safety InspectionProperly installed electrical wiring and equipment.
DFewPotential for HarmFire Safety InspectionExits that are accessible at all times.
DFewPotential for HarmFire Safety InspectionSpecial areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system.

February 18, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Payment DenialPayment denial for 36 days
FManyPotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
FManyPotential for HarmComplaint+InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
ESomePotential for HarmHealth InspectionKeep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.
ESomePotential for HarmHealth InspectionHave a program that investigates, controls and keeps infection from spreading.
DFewPotential for HarmComplaint+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 that residents are fully informed and understand their health status, care and treatments.
DFewPotential for HarmComplaintProtect each resident from all abuse, physical punishment, and involuntary separation from others.
DFewPotential for HarmComplaint+InspectionGive proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible.
DFewPotential for HarmComplaint+InspectionEvaluate a residentís decrease in social interaction or increase in depressive behaviors and determine if the behavioral changes were avoidable if these problems did not exist before.
DFewPotential for HarmHealth InspectionEnsure each resident receives an accurate assessment by a qualified health professional.
DFewPotential for HarmComplaint+InspectionProvide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
DFewPotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
DFewPotential for HarmHealth InspectionEnsure that residents are safe from serious medication errors.

September 11, 2014 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
GFewActual HarmComplaintEnsure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
DFewPotential for HarmComplaintProvide necessary care and services to maintain or improve the highest well being of each resident .

April 28, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$126,620 fine
LManyImmediate JeopardyComplaint+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.
KSomeImmediate JeopardyComplaint+InspectionProtect each resident from all abuse, physical punishment, and involuntary separation from others.
FManyPotential for HarmHealth InspectionSet up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action.
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) Review the work of each nurse aide every year; and 2) give regular in-service training based upon these reviews.
FManyPotential for HarmComplaint+InspectionHave enough nurses to care for every resident in a way that maximizes the resident's well being.
FManyPotential for HarmHealth InspectionStore, cook, and serve food in a safe and clean way.
FManyPotential for HarmHealth InspectionMake sure that the facility is administered in an acceptable way that maintains the well-being of each resident .
ESomePotential for HarmComplaint+InspectionAssist those residents who need help with eating/drinking, grooming and personal and oral hygiene.
ESomePotential for HarmHealth InspectionProperly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
ESomePotential for HarmHealth InspectionProvide necessary care and services to maintain or improve the highest well being of each resident .
CManyPotential for Minimal HarmHealth InspectionEstablish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility
CManyPotential for Minimal HarmHealth InspectionPost nurse staffing information/data on a daily basis.
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 HarmComplaint+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 InspectionProvide activities to meet the interests and needs of each resident.
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 InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaint+InspectionGive residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.

April 9, 2014 - 3 years ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmFire Safety InspectionProperly protected cooking facilities.

Staffing Levels Per Resident per Day

Medicare determines the expected staffing time per resident per day depending on level of care the residents of Victoria Falls 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 25min
2hr 15min
ReportedExpected
CNA
1hr
40min
ReportedExpected
LPN
35min
60min
ReportedExpected
RN
4hr 60min
3hr 50min
ReportedExpected
Total Nursing

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

Quality Measures for Long Stay Residents

97.8%
80.0%
80.0%
96.5%
Q1 2015Q2 2015Q3 2015KS
Assessed and Appropriately Given the Seasonal Influenza Vaccine
100.0%
100.0%
100.0%
93.5%
Q1 2015Q2 2015Q3 2015KS
Assessed and Appropriately Given the Pneumococcal Vaccine
-
-
-
40.2%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
Low Risk Residents Who Lose Control of Their Bowel or Bladder
36.7%
29.2%
23.5%
19.9%
Q1 2015Q2 2015Q3 2015KS
Received an Antipsychotic Medication
18.2%
25.5%
17.4%
17.5%
Q1 2015Q2 2015Q3 2015KS
Need for Help with ADLs has Increased
4.9%
9.0%
7.5%
11.0%
Q1 2015Q2 2015Q3 2015KS
Self Report Moderate to Severe Pain
18.2%
4.2%
12.2%
7.4%
Q1 2015Q2 2015Q3 2015KS
Lose Too Much Weight
-
-
-
5.3%
Q1 2015Q2 2015Q3 2015KS
* The data for this facility for some quarters is unavailable.
High Risk Residents With Pressure Ulcers
0.0%
0.0%
0.0%
7.1%
Q1 2015Q2 2015Q3 2015KS
Have Depressive Symptoms
1.9%
1.9%
0.0%
6.6%
Q1 2015Q2 2015Q3 2015KS
With a Urinary Tract Infection
5.6%
1.8%
5.2%
5.0%
Q1 2015Q2 2015Q3 2015KS
Experiencing One or More Falls with Major Injury
4.7%
1.8%
4.4%
3.0%
Q1 2015Q2 2015Q3 2015KS
With a Catheter Inserted and Left in Their Bladder
0.0%
0.0%
0.0%
0.3%
Q1 2015Q2 2015Q3 2015KS
Were Physically Restrained

Quality Measures for Short Stay Residents

100.0%
100.0%
100.0%
77.6%
Q1 2015Q2 2015Q3 2015KS
Assessed and Appropriately Given the Pneumococcal Vaccine
100.0%
86.5%
86.5%
77.9%
Q1 2015Q2 2015Q3 2015KS
Were Assessed and Appropriately Given the Seasonal Influenza Vaccine
15.7%
25.6%
17.9%
21.2%
Q1 2015Q2 2015Q3 2015KS
Self Report Moderate to Severe Pain
5.4%
2.7%
3.0%
2.7%
Q1 2015Q2 2015Q3 2015KS
Newly Received an Antipsychotic Medication
6.2%
3.6%
2.4%
1.5%
Q1 2015Q2 2015Q3 2015KS
With Pressure Ulcers That Are New or Worsened