ST. JOHN'S OF VICTORIA

The nursing staff is the most important part of what determines the quality of care and comfort of a resident in a nursing home. Government regulations set expectations on time spent with each resident based on the services being provided. The breakdown below lists the nursing types (RN, LPN, LVN, CNA) and a comparison of the reported and expected hours per resident per day.

Medicare determines quality of care ratings for nursing facilities by surveying several "quality measures", which are broken down into long-term and short-term stay residents, as well as if the action is preventive or if there is a deficiency in the quality of care. State averages for Kansas are also provided for comparison purposes. Note: Figures below are averaged over the past nine months.

Long-Term Stay Preventive Actions

Long-Term Stay Deficiencies

All Medicare and/or Medicaid certified nursing home must undergo health inspections on average once a year, but may be more frequent if the facility is peforming poorly. These inspections cover most aspects of life in a nursing home, and are broken down into deficiencies types, which including: Pharmacy Service, Administration, Resident Rights, Nutrition and Dietary, Resident Assessment, Environmental, and Mistreatment. Below are the list of deficiencies found by inspectors in the past few years along with the degree of harm and how many residents may have been affected. Note: The most recent health survey was on 02/01/2011.

Administration

Choose a Doctor to Be the Medical Director. Inspection Date: 10/16/2008 Correction Date: 11/14/2008
Keep Accurate and Appropriate Medical Records. Inspection Date: 11/09/2009 Correction Date: 12/08/2009

Environmental

Provide Needed Housekeeping and Maintenance. Inspection Date: 10/16/2008 Correction Date: 11/14/2008
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Have a Program to Keep Infection from Spreading. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Provide at Least One Room to Use As a Dining Room and for Activities, That is a Good Size, with Good Lighting, Airflow and Furniture. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Make Sure That the Nursing Home Area is Free of Dangers That Cause Accidents. Inspection Date: 02/01/2011 Correction Date: 04/12/2011

Nutrition and Dietary

Offer Other Nutritional Food to Each Resident Who Will Not Eat the Food Served. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Store, Cook, and Give out Food in a Safe and Clean Way. Inspection Date: 11/09/2009 Correction Date: 12/08/2009

Pharmacy Service

1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Keep the Rate of Medication Errors (Wrong Drug, Wrong Dose, Wrong Time) to Less Than 5%. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Have Drugs and Other Similar Products Available, Which Are Needed Every Day and in Emergencies, and Give Them out Properly. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
At Least Once a Month, Have a Licensed Pharmacist Check the Drugs That Each Resident Takes. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
1) Make Sure That Residents Who Take Drugs Are Not Given Too Many Doses or for Too Long; 2) Make Sure That the Use of Drugs is Carefully Watched; or 3) Stop or Change Drugs That Cause Unwanted Effects. Inspection Date: 02/01/2011 Correction Date: 03/07/2011

Quality Care

Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion. Inspection Date: 10/16/2008 Correction Date: 11/14/2008
Give Professional Services That Meet a Professional Standard of Quality. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Give Residents Proper Treatment to Prevent New Bed (Pressure) Sores or Heal Existing Bed Sores. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Make Sure That Residents with Reduced Range of Motion Get Proper Treatment and Services to Increase Range of Motion. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Give Each Resident Enough Fluids to Keep Them Healthy and Prevent Dehydration. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Have Enough Nurses to Care for Every Resident in a Way That Maximizes the Resident's Well Being. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Provide Activities to Meet the Needs of Each Resident. Inspection Date: 02/01/2011 Correction Date: 03/07/2011
Give Each Resident Care and Services to Get or Keep the Highest Quality of Life Possible. Inspection Date: 02/01/2011 Correction Date: 03/07/2011
Make Sure That Residents Who Cannot Care for Themselves Receive Help with Eating/Drinking, Grooming and Hygiene. Inspection Date: 02/01/2011 Correction Date: 04/12/2011
Make Sure That Each Resident Who Enters the Nursing Home Without a Catheter is Not Given a Catheter, Unless It is Necessary. Inspection Date: 02/01/2011 Correction Date: 03/07/2011
Make Sure That Each Resident's Nutritional Needs Were Met. Inspection Date: 02/01/2011 Correction Date: 04/12/2011
Have Enough Nurses to Care for Every Resident in a Way That Maximizes the Resident's Well Being. Inspection Date: 02/01/2011 Correction Date: 04/12/2011

Resident Assessment

Make a Complete Assessment That Covers All Questions for Areas That Are Listed in Official Regulations. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Develop a Complete Care Plan That Meets All of a Resident's Needs, with Timetables and Actions That Can Be Measured. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
1) Develop a Complete Care Plan Within 7 Days of Each Resident's Admission; 2) Prepare a Care Plan with the Care Team, Including the Primary Nurse, Doctor, Resident or Resident's Family or Representative; or 3) Check and Update the Care Plan. Inspection Date: 02/01/2011 Correction Date: 03/07/2011

Resident Rights

Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Make Sure Each Resident Has the Right to Choose Activities, Schedules and Health Care According to His or Her Interests, Assessment, and Plan of Care. Inspection Date: 11/09/2009 Correction Date: 12/08/2009
Provide Care in a Way That Keeps or Builds Each Resident's Dignity and Self Respect. Inspection Date: 02/01/2011 Correction Date: 04/12/2011
Make Sure Each Resident Has the Right to Choose Activities, Schedules and Health Care According to His or Her Interests, Assessment, and Plan of Care. Inspection Date: 02/01/2011 Correction Date: 03/07/2011

Nursing homes certified by Medicare and/or Medicaid are required to have fire safety inspections to meet Life Safety Code (LSC) standards. Below is a list of deficiencies that St. John's of Victoria had in recent fire safety inspections. This information can be used to see if all standards were met, the degree of harm, the number of residents affected, and the date when deficiencies were corrected. Note: The most recent fire safety survey was on 10/12/2010.

Automatic Sprinkler Systems

Automatic Sprinkler Systems That Have Been Maintained in Working Order. Inspection Date: 10/20/2008 Correction Date: 10/29/2008

Building Construction

Approved Construction Type or Materials. Inspection Date: 10/20/2008 Correction Date: 10/23/2008

Corridor Walls and Doors

Corridor and Hallway Doors That Block Smoke. Inspection Date: 10/20/2008 Correction Date: 10/28/2008
Corridors That Are Separated from Common Areas by Walls Constructed to Limit the Passage of Smoke. Inspection Date: 10/06/2009 Correction Date: 10/20/2009

Electrical

Weekly Inspections and Monthly Testing of Generators. Inspection Date: 10/20/2008 Correction Date: 10/23/2008
Properly Installed Electrical Wiring and Equipment. Inspection Date: 10/20/2008 Correction Date: 10/24/2008
Weekly Inspections and Monthly Testing of Generators. Inspection Date: 10/06/2009 Correction Date: 10/09/2009

Emergency Plans and Fire Drills

Record of Quarterly Fire Drills for Each Shift Under Varying Conditions. Inspection Date: 10/20/2008 Correction Date: 10/27/2008

Exits and Egress

Exit Stairways and Towers That Are Smoke Proof. Inspection Date: 10/20/2008 Correction Date: 10/28/2008

Fire Alarm Systems

Properly Maintained Smoke Detectors. Inspection Date: 10/20/2008 Correction Date: 11/18/2008
A Fire Alarm System That Can Be Heard Throughout the Facility. Inspection Date: 10/12/2010 Correction Date: 10/13/2010

Hazardous Area

Construction That Can Resist Fire for One Hour or an Approved Fire Extinguishing System. Inspection Date: 10/20/2008 Correction Date: 10/21/2008

Illumination and Emergency Power

Proper Backup Exit Lighting. Inspection Date: 10/20/2008 Correction Date: 11/18/2008

Interior Finish

Fire-Resistant Room Wall Surfaces. Inspection Date: 10/20/2008 Correction Date: 11/18/2008

Smoke Compartmentation and Control

Walls or Barriers That Prevent Smoke from Passing Through and Would Resist Fire for at Least One Hour. Inspection Date: 10/20/2008 Correction Date: 10/23/2008

Smoking Regulations

Posted "No-Smoking" Signs in Areas Where Smoking is Not Permitted or Did Not Provide Ashtrays Where Smoking Was Allowed. Inspection Date: 10/20/2008 Correction Date: 10/24/2008