Provena Our Lady of Victory

Total Number of Beds: 107	Percent of Occupied Beds: 94%
Total Number of Residents: 101	Located Within a Hospital: No
Type of Ownership: Non profit - Corporation	Multiple Nursing Homes by Same Owner: Yes
Councils the Nursing Home Participates in: Family & Resident	Medicare/Medicaid: Participating in Medicare and Medicaid
* Details Last Reported on: 09/19/2003

Nursing Home Staff Information:

Number of RN Hours per Nursing Home Resident per Day: 0.45

Number of LPN/LVN Hours per Nursing Home Resident per Day: 0.68

Number of CNA Hours per Nursing Home Resident per Day: 1.08

Number of Staff Hours per Nursing Home Resident per Day: 2.21

Nursing Home Resident Information**:

Percent of Low-Risk Residents Who Have Pressure Sores: 4%
Percent of Short-Stay Residents With Pressure Sores: 20%
Percent of High-Risk Residents Who Have Pressure Sores: 7%
Percent of Short-Stay Residents Who Had Moderate to Severe Pain: 14%
Percent of Residents Who Have Moderate to Severe Pain: 6%
Percent of Residents Whose Ability to Move About in and Around Their Room Got Worse: 8%
Percent of Residents Who Spend Most of Their Time in Bed or in a Chair: 4%
Percent of Residents Whose Need for Help With Daily Activities Has Increased: 10%
Percent of Residents Who are More Depressed or Anxious: 13%
Percent of Short-Stay Residents With Delirium: 9%
Percent of Residents Who Were Physically Restrained: 5%
Percent of Low-Risk Residents Who Lose Control of Their Bowels or Bladder: 42%
Percent of Residents Who Have/Had a Catheter Inserted and Left in Their Bladder: 11%
Percent of Residents With a Urinary Tract Infection: 13%
** Details Last Reported on: 9/19/2003

Nursing Home Inspection Violations:

Date of Violation	Date Corrected	Type of Violation	Deficiency	Scope	Level of Harm
2001-09-26	2001-10-17	Resident Rights Deficiencies	Keep each resident's personal and medical records private and confidential.	Pattern	Potential for minimal harm
2001-09-26	2001-10-17	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Potential for minimal harm
2001-09-26	2001-10-01	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
2001-09-26	2001-10-17	Nutrition and Dietary Deficiencies	Store, cook, and give out food in a safe and clean way.	Widespread	Potential for minimal harm
2002-10-02	2003-01-17	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Actual harm
2002-10-02	2002-11-27	Quality Care Deficiencies	Make sure that residents with reduced range of motion get proper treatment and services to increase range of motion.	Isolated	Minimal harm or potential for actual harm
2002-10-02	2002-11-27	Quality Care Deficiencies	Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
2002-10-02	2002-11-27	Environmental Deficiencies	Make sure that staff members wash their hands when needed.	Isolated	Minimal harm or potential for actual harm
2002-10-02	0000-00-00	Environmental Deficiencies	Move, clean and store sheets, towels and other linens in a way that prevents the spread of infection.	Widespread	Potential for minimal harm
2003-09-19	2003-10-07	Resident Rights Deficiencies	Quickly give a resident's personal money to the heads of his or her estate after the resident's death.	Pattern	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Resident Rights Deficiencies	Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm
2003-09-19	2003-10-07	Mistreatment Deficiencies	Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Mistreatment Deficiencies	Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Pattern	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Resident Rights Deficiencies	Provide care in a way that keeps or builds each resident's dignity and self respect.	Pattern	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Resident Rights Deficiencies	Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Quality Care Deficiencies	Make sure that residents receive treatment/services to continue to be able to care for themselves, unless a change is unavoidable.	Isolated	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Quality Care Deficiencies	Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores.	Isolated	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Quality Care Deficiencies	Make sure that residents with loss of bladder control receive treatment or service to prevent infections and help get normal bladder control.	Pattern	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Environmental Deficiencies	Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Pharmacy Service Deficiencies	Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Pharmacy Service Deficiencies	Make sure that residents are safe from serious medication errors.	Isolated	Immediate jeopardy to resident health or safety
2003-09-19	2003-10-07	Quality Care Deficiencies	Have enough nurses to care for every resident in a way that maximizes the resident's well being.	Pattern	Minimal harm or potential for actual harm
2003-09-19	2003-10-07	Administration Deficiencies	Get proof that a nurse aide has the training and skills that the State requires.	Isolated	Minimal harm or potential for actual harm

*** All violations listed are based on federal government records.