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Retama Manor Nursing Center/victoria South

Details

Type of Ownership For profit - Corporation
Participates in Medicare? Yes
Participates in Medicaid? Yes
Certified Beds 142
Continuing Care? No
Resident Council? Yes
Family Council? Yes
Multi-Home Chain? No
Located in a Hospital? No
Special Focus Facility? No

View:    Health Inspections  |  Quality Measures  |  Staffing  |  Fire Inspections

Health Inspections  

Most Recent Inspection: 01/17/2012

Date of last standard health inspection: 01/17/2012
Quality Indicator Survey No
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Health Deficiencies for this nursing home: 3
Average number of Health Deficiencies in TX: 3
Average number of Health Deficiencies in US: 3
Range of Health Deficiencies in TX: 0 - 19
Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident. 01/00/2012 01/04/2001 1 Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly 01/00/2012 01/04/2001 Many and develop corrective plans of action.
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 01/00/2012 01/04/2001 2 Some

Inspection, 01/00/2012

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident. 01/00/2012 01/04/2001 1 Many
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. 01/00/2012 03/00/2012 2 Some
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. 01/00/2012 01/04/2001 2 Many
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. 01/00/2012 01/04/2001 2 Some
Have a program that investigates, controls and keeps infection from spreading. 01/00/2012 01/04/2001 2 Some
Keep all essential equipment working safely. 01/00/2012 01/05/2012 2 Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. 01/00/2012 01/04/2001 1 Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 01/00/2012 01/04/2001 2 Some
Mistreatment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
1) 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. 01/00/2012 01/04/2001 2 Few
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. 01/00/2012 01/04/2001 2 Some
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 01/00/2012 01/04/2001 2 Some
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. 01/00/2012 01/04/2001 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 01/00/2012 01/04/2001 2 Some
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 01/00/2012 01/04/2001 2 Few
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep residents' personal and medical records private and confidential. 01/00/2012 01/04/2001 2 Few
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. 01/00/2012 00/06/2001 2 Some

Inspection, 01/08/2011

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate 01/08/2011 02/06/2012 Some complete and organized clinical records on each re
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 01/08/2011 02/06/2012 2 Some

Inspection, 02/08/2010

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 02/08/2010 00/09/2011 2 Some
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 02/08/2010 00/09/2011 2 Some
Resident Rights Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Reasonably accommodate the needs and preferences of each resident. 02/08/2010 00/09/2011 2 Few

Inspection, 02/04/2009

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate 02/04/2009 01/04/2010 Some complete and organized clinical records on each re

Inspection, 00/09/2009

Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide housekeeping and maintenance services. 00/09/2009 02/07/2009 2 Some

Inspection, 02/06/2008

Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 02/06/2008 02/00/2009 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Assist those residents who need help with eating/drinking 02/06/2008 02/01/2009 Few grooming and personal and oral hygiene.
Use a registered nurse at least 8 hours a day 02/06/2008 02/07/2008 Many 7 days a week.

Inspection, 01/07/2008

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. 01/07/2008 01/09/2008 2 Some

Inspection, 02/02/2003

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. 02/02/2003 00/01/2004 2 Some
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep all essential equipment working safely. 02/02/2003 00/01/2004 2 Some
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. 02/02/2003 00/00/0000 1 Some
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 02/02/2003 00/01/2004 2 Some

Inspection, 02/07/2001

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Keep accurate 02/07/2001 01/05/2002 Some complete and organized clinical records on each re
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 02/07/2001 01/05/2002 2 Some

Inspection, 01/07/2001

Administration Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Post nurse staffing information/data on a daily basis. 01/07/2001 01/08/2001 1 Many
Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. 01/07/2001 00/01/2002 2 Few
Environmental Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Have a program that investigates, controls and keeps infection from spreading. 01/07/2001 00/01/2002 2 Few
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. 01/07/2001 01/08/2001 1 Some
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 01/07/2001 01/07/2002 1 Some
Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 01/07/2001 01/08/2001 2 Some
Quality Care Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide care by qualified persons according to each resident's written plan of care. 01/07/2001 00/01/2002 2 Few
Provide necessary care and services to maintain or improve the highest well being of each resident. 01/07/2001 01/08/2001 2 Some
Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. 01/07/2001 01/08/2001 2 Some
Resident Assessment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. 01/07/2001 01/08/2001 2 Some

Inspection, 01/00/2001

Pharmacy Service Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. 01/00/2001 01/05/2002 2 Some

Nursing Home Staffing  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

National Average Average in TX Golden Living Center, Asheville
RN Staff Only1 N/A N/A 1 out of 5 stars
Total Number of Residents 86 72 105
Total, Licensed Nurse Staff Hours
per Resident per Day
16 hours 51 minutes 29 hours 19 minutes 1 hour 24 minutes
RN Hours
per Resident per Day
16 hours 3 minutes 28 hours 29 minutes 27 minutes
LPN/LVN Hours
per Resident per Day
16 hours 17 minutes 29 hours 31 minutes 56 minutes
CNA Hours
per Resident per Day
17 hours 46 minutes 30 hours 19 minutes 2 hours 3 minutes

1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.

Quality Measures  

Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.

Long-Term Residents

Short-Term Residents

Fire Safety Inspections

Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.

Most Recent Inspection: 01/13/2012

Automatic Sprinkler Systems in all required areas Yes
Date of last standard fire safety inspection: 01/13/2012
Dates of Complaint Investigations: 04/01/2011 - 03/31/2012
Total number of Fire Safety Deficiencies for this nursing home: 0
Average number of Fire Safety Deficiencies in TX: 1
Average number of Fire Safety Deficiencies in US: 2
Range of Fire Safety Deficiencies in TX: 0 - 1

Inspection, 00/08/2012

Corridor Walls and Doors Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Corridor and hallway doors that block smoke. 00/08/2012 01/06/2001 2 Some
Emergency Plans and Fire Drills Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Record of quarterly fire drills for each shift under varying conditions. 00/08/2012 01/06/2001 1 Many
Furnishings and Decorations Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are free from obstructions and can be used at all times. 00/08/2012 01/06/2001 2 Some
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 00/08/2012 01/06/2001 1 Some
Medical Gases and Anesthetizing Areas Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Proper medical gas storage and administration areas. 00/08/2012 01/06/2001 1 Some

Inspection, 02/00/2003

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved automatic sprinkler system connected to the fire alarm system. 02/00/2003 02/03/2005 2 Many
Building Service Equipment Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. 02/00/2003 00/00/0000 1 Many
Fire Alarm Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
An approved installation, maintenance and testing program for fire alarm systems. 02/00/2003 01/06/2004 1 Many

Inspection, 01/03/2001

Automatic Sprinkler Systems Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Automatic sprinkler systems that have been maintained in working order. 01/03/2001 03/01/2001 1 Many
Portable fire extinguishers. 01/03/2001 03/01/2001 1 Many
Exits and Egress Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Exits that are accessible at all times. 01/03/2001 00/01/2002 2 Many
Hazardous Area Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Special areas constructed so that walls can resist fire for one hour or an approved fire extinguishing system. 01/03/2001 03/01/2001 2 Some
Smoke Compartmentation and Control Deficiencies
Deficiency Inspection Date Correction Date Level of Harm Residents Affected
Walls that prevent smoke from passing through and would resist fire for at least one hour. 01/03/2001 00/02/2002 2 Some
 

3103 E Airline Dr
Victoria, TX 77901

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