Victorian Village Hlth & Well

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the transfer method recommended by physical therapy and indicated in the resident's plan of care. This failure resulted in R1 sustaining a 12cm (centimeter) left lower leg laceration, transfer to the hospital, and laceration repair with 21 sutures. This applies to 1 resident (R1) reviewed for safe transfers in a sample of 4.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow the planned menu plan for residents on diabetic diets. This applies to 4 of 4 residents (R10, R198, R202, R248) reviewed for dining in the sample of 13.

Inspectors wrote2. Face sheet showed R21 is 73 years-old who has multiple medical diagnoses including aftercare following joint replacement surgery and infection and inflammatory reaction due to internal right knee prosthesis, subsequent encounter. Care plan dated June 9, 2025, shows R21 is receiving intravenous (IV) antibiotic therapy for 35 days related to prosthetic joint infection after a total knee arthroplasty (TKA). R21 was in his room on June 30, 2025, from 12:14PM until 12:40PM receiving care from V13 (Nurse). R21's room was noted with a sign showing, Enhanced Barrier Precautions and a set-up was noted outside R21's room door. During this time, V12 provided care to R21 (flushing an IV line, applying compression socks and changing dressing to the wound) without wearing an isolation gown. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision during meals. This applies to 1 of 1 resident (R201) reviewed for eating supervision in the sample of 13

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure regarding privacy and confidentiality of health information. This applies to 2 of the 3 residents (R2, R3) reviewed for privacy/confidentiality in the sample of 5.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all prescribed medication was provided to the resident upon discharge. This applies to 1 of 3 residents (R1) reviewed for discharge process in the sample of 5.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to all 46 residents in the facility receiving dietary services.

Inspectors wroteBased on interview and record review, the facility failed to offer COVID-19 vaccines to the facility's staff members and failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. This has the potential to affect all residents at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to follow manufacturer guidelines for blood glucose monitoring. This applies to one resident (R35) reviewed for quality of care in a sample of 19.

Inspectors wroteBased on observation, interview, & record review, the facility failed to provide ADL care (activities of daily living) to dependent residents. This applies to 3 of 4 residents (R24, R27, & R30) reviewed for ADL care in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain indwelling urinary catheter according to best practice to prevent complications. This applies to 1 resident (R151) reviewed for urinary catheter in a sample of 19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician medication orders. This applies to one resident (R146) reviewed for quality of care in a sample of 19.

Inspectors wroteBased on observation, interview, & record review, the facility failed to provide proper hand hygiene during incontinence care & while providing a physical exam. This applies to 3 of 4 residents (R24, R96, & R16) reviewed for bowel and bladder incontinence, and 1 of 4 residents (R30) reviewed for ADL care (Activities of Daily Living) in a sample of 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to store pots and pans in a sanitary manner and failed to discard dented cans. This applies to all 49 residents that reside in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide diet as ordered by the Physician. This applies to 5 of 5 residents (R1, R2, R11, R27, R30) reviewed for diet orders in the sample of 13.

Inspectors wroteBased on observation and interview; the facility failed to maintain an effective pest control program. This applies to 5 of 5 (R9, R14, R15, R20, R31) residents reviewed for environment in a sample of 13.

Inspectors wroteBased on observation and interview the facility failed to ensure call lights were within reach of residents and operational. This applies to 3 of 3 residents (R17, R247, R250) reviewed for call lights in the sample of 13.

Inspectors wroteBased on observation and interview the facility failed to provide privacy during a blood draw. This applies to 1 of 1 resident (R248) observed for blood draws in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and provide adaptive device/equipment to a resident, to prevent further reduction in mobility and ROM (range of motion). This applies to 1 of 1 resident (R12) reviewed for mobility and range of motion in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident's urinary catheter tubing was kept off the floor to prevent potential urinary tract infection and trauma to the urinary tract. This applies to 1 of 2 residents (R5) reviewed for indwelling urinary catheter in the sample of 13.

Inspectors wroteBased on observation, interview and record review the facility failed to provide oxygen therapy as ordered by the Physician. This applies to 2 of 2 residents (R10, R11) reviewed for oxygen in the sample of 13.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their infection control policy and don personal protective equipment (PPE) required for transmission based precautions, and also failed to perform hand hygiene upon entering and exiting a room requiring transmission based precautions. This applies to 3 of 3 residents (R19, R249, R250) reviewed for infection control in the sample of 13.