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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 CouncilsResident
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

August 31, 2016 - 7 months ago

 Residents AffectedSeveritySource/TypeDescription
DFewPotential for HarmComplaintConduct initial and periodic assessments of each resident's functional capacity.
DFewPotential for HarmComplaintHelp and prepare each resident for a safe and easy discharge or transfer from the nursing home.
DFewPotential for HarmComplaintProvide timely notification to the resident before transfer or discharge.

June 10, 2016 - 10 months ago

 Residents AffectedSeveritySource/TypeDescription
ESomePotential for HarmComplaint+InspectionMake sure that a working call system is available in each resident's room or bathroom and bathing area.
DFewPotential for HarmComplaint+InspectionAt least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
DFewPotential for HarmComplaint+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 HarmComplaint+InspectionProperly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses.
DFewPotential for HarmComplaint+InspectionDevelop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
DFewPotential for HarmComplaint+InspectionAllow residents the right to participate in the planning or revision of care and treatment.
DFewPotential for HarmComplaint+InspectionProvide activities to meet the interests and needs of each resident.

October 9, 2015 - 18 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 - 2 years 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.

February 18, 2015 - 2 years ago

 Residents AffectedSeveritySource/TypeDescription
---Fine$15,340 fine
---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 - 3 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.

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.

4hr 15min
2hr 10min
ReportedExpected
CNA
1hr 10min
40min
ReportedExpected
LPN
35min
60min
ReportedExpected
RN
5hr 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

80.0%
83.8%
83.8%
83.8%
95.4%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine
90.6%
100.0%
100.0%
100.0%
92.8%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine
0.0%
8.0%
12.5%
14.8%
39.7%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of low risk long-stay residents who lose control of their bowels or bladder
21.1%
30.9%
33.9%
23.2%
24.3%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who received an antianxiety or hypnotic medication
20.4%
9.1%
34.0%
31.0%
19.3%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents whose ability to move independently worsened
21.4%
25.5%
32.0%
26.9%
20.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who received an antipsychotic medication
18.9%
19.6%
27.8%
14.8%
16.7%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents whose need for help with daily activities has increased
5.6%
3.3%
1.6%
2.9%
10.4%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who self-report moderate to severe pain
12.3%
11.5%
3.4%
6.6%
7.5%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who lose too much weight
12.0%
4.0%
0.0%
5.0%
5.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of high risk long-stay residents with pressure ulcers
0.0%
0.0%
0.0%
0.0%
6.4%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who have depressive symptoms
0.0%
3.2%
1.7%
3.2%
6.0%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents with a urinary tract infection
4.7%
3.2%
5.1%
6.3%
4.8%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents experiencing one or more falls with major injury
3.5%
2.9%
1.5%
1.5%
2.6%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents with a catheter inserted and left in their bladder
0.0%
0.0%
0.0%
0.0%
0.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of long-stay residents who were physically restrained

Quality Measures for Short Stay Residents

89.4%
90.7%
98.2%
100.0%
76.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine
86.5%
79.6%
79.6%
79.6%
74.2%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine
-
-
-
-
69.5%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who made improvements in function
-
0.0%
0.0%
12.9%
20.9%
Q4 2015Q1 2016Q2 2016Q3 2016KS
* The data for this facility for some quarters is unavailable.
Percentage of short-stay residents who self-report moderate to severe pain
4.0%
3.6%
0.0%
2.9%
2.7%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of short-stay residents who newly received an antipsychotic medication
0.0%
3.0%
7.2%
4.9%
1.9%
Q4 2015Q1 2016Q2 2016Q3 2016KS
Percentage of short-stay residents with pressure ulcers that are new or worsened