Victoria Gardens of Allen

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety 1 of 1 kitchen. 1. The facility failed to ensure food items were labeled and dated in the walk-in refrigerator.2. The facility failed to ensure expired food items were not in the walk-in refrigerator.3. The Dietary Manager failed to ensure lunch food temperatures were checked on the steam table line. These failures could place residents at risk of food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 4 residents (Resident #1 and Resident #2) reviewed for resident rights. The facility failed to ensure staff didn't tell Resident #1 to use her brief to go to the bathroom. This failure could place residents at risk of a decrease in quality of life.

Inspectors wroteBased on observation and interview the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, permitted only authorized personnel to have access to the for 2 (MC#1 and TC#2) of 3 carts on 04/14/26. This failure could place residents at risk of drug diversion.

Inspectors wroteBased on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 2 residents (Resident #8), reviewed for resident assessment. Resident #8's PASRR level 1 screening form did not reflect mental illness, and the resident did not have a PASRR level II evaluation .This could place residents at risk of not receiving necessary specialized services to meet their individual needs.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a resident receives treatment and care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one (Resident #95) of four residents reviewed for quality of care. The facility failed to ensure RN I completed wound cares to Resident #95 per physician orders. This failure placed residents at risk for the decline in quality of life and the wounds being infected or deteriorating. Review of Resident #95's face sheet dated 02/11/26 revealed he was a [AGE] year-old male, and he was admitted on [DATE]. Admitting diagnoses included, type 2 diabetes, acquired abscess of the left toe, peripheral vascular disease, and chronic osteomyelitis (Reduced blood flow (ischemia) from narrowed arteries limits immune response) left ankle and foot. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for one of six residents (Resident #75) observed for infection control. The facility failed to ensure CNA D completed hand hygiene while providing incontinence care to Resident # 75. This failure could place the residents at risk of infection. Record review of Resident #75's face sheet dated 02/11/26 reflected a [AGE] year-old female. She was admitted to the facility 01/14/26. Admitting diagnoses included hypertension, pressure ulcer to the sacrum area (located at the base of the spine) muscle weakness, neuromuscular dysfunction of the bladder (person lacks bladder control)and muscle wasting and atrophy. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 9 rooms (Rooms 104, 105, 108, 209, 212, 306, 307, and 312) of 30 rooms reviewed for accident hazards. The facility failed to ensure the needle sharps containers (which are specialized receptacles designed to safely dispose of sharp medical instruments that can cause injuries or infections) in Rooms 104, 105, 108, 209, 212, 306, 307, and 312 were emptied. This failure could place residents at risk of being injured by a needle, and exposure to bloodborne pathogens.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident records were maintained for each resident that were complete; accurately documented, readily accessible; and systematically organized for 1 of 9 residents (Resident #1) reviewed for resident records. LVN B failed to document a telephone order from the physician for Resident #1's cough medicine, guaifenesin. This failure could result in residents not receiving the medication ordered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #1 and Resident #2) of five residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #1's breathing mask for nebulization was properly stored on 12/07/2024. 2. The facility failed to ensure that Resident #2's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored on 12/07/2024. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #2) of five residents reviewed for Infection Control. The facility failed to ensure that CNA B changed his gloves and performed hand hygiene while providing incontinent care to Resident #2 on 12/07/2024. This failure could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for one (Resident #81) of eight residents reviewed for ADL care. 1. The facility failed to provide Resident #81 with timely incontinence care on 11/17/24. This failure could place residents at risk for a skin breakdown and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #8) of 3 residents reviewed for pressure ulcers. The facility failed to provide wound care for Resident #8 on 11/16/24 and 11/17/24. This failure could place residents with pressure wounds at risk of the wound worsening, leading to increased pain, infection, delayed healing, serious complications including sepsis, reduced mobility, and a lower quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #9, Resident 47, and Resident #72) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #9 was shaved and not having facial hair. 2- Resident #47 had her fingernails cleaned and trimmed. 3- Resident #72 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 (Resident #14, Resident #34, Resident #66, and Resident#69) of 8 residents reviewed for infection control. The facility failed to ensure: 1- RN L disinfected the glucometer in between blood sugar checks for Residents #66 and #69. 2- MA M disinfected the blood pressure cuff in between blood pressure checks for Residents #14 and #34. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident received services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #93) of 7 residents reviewed for call lights. The facility failed to ensure Resident #93's call button was within reach. This failure could place residents at risk for decreased quality of life, self-worth and dignity.

Inspectors wroteBased on observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #47 and #93) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to implement a care plan and implement interventions for Resident #47's ADL deficits of hygiene. 2. The facility failed to implement a care plan for Resident #93's specialized call light device. These failures could place residents at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #250) of one resident reviewed for respiratory care in that: RN E failed to follow the procedure for tracheostomy care for Resident #250 when he failed to maintain a sterile/clean field for supplies necessary for care and failed to change his gloves and perform hand hygiene during tracheostomy care when going from dirty to clean multiple times. These failures could place residents with tracheostomies at risk for respiratory infections and the risk of lung infections.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses cart hall 400) of 2 carts reviewed for pharmacy services. The facility failed to ensure LVN C and RN K counted controlled drugs every shift change. This failure could result in an inaccurate controlled medication count, and drug diversion. Findings Included: Record review and random count observation of 400 hall nurse's cart with LVN C on 09/26/2023 at 12:28 PM revealed missing signatures for Off duty and On duty for 08/21/2023, 08/31/2023, 09/02/2023, 09/08/2023 of the narcotic count sheet. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide liquids consistent with the residents' needs, for one (Resident #85) of three residents reviewed for liquid inconsistency, in that: Resident #85 was not served nectar thickened coffee during her breakfast meal on 09/28/23. This failure could place residents who have dysphagia at risk for aspiration.

Inspectors wroteBased on interview and record review, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient, hospice election form, the physician certification and recertification of the terminal illness specific to each patient and hospice medication information specific to each patient for one (Residents #24) of two residents reviewed for hospice. The facility failed to obtain the required hospice documentation for Resident #24 including hospice election form, the physician recertification of terminal illness, updated hospice plan of care and updated medication list from Hospice O. This failure could result in services and treatments not being coordinated.