Victory Health and Rehabilitation Center

Inspectors wroteBased on interview and document review, the facility failed to perform complete and thorough investigations of allegations of abuse for 3 of 3 residents (R1, R2, R3) who were involved in resident-to-resident altercations.

Inspectors wroteBased on interview and document review the facility failed to ensure a safe environment was maintained and monitoring was implemented as indicated in the medical record for 2 of 3 residents (R1, R3), and as ordered for 1 of 3 residents (R2) after resident-to-resident altercations. Additionally, the facility failed to ensure ongoing assessment and monitoring for 2 of 2 residents (R1, R3) after R1 was hit and scratched by R2, and R3 was hit in the torso and slapped by R2, which had the potential to result in unmonitored decline for R1 and R3.

Inspectors wroteF880Based on observation, interview and document review the facility failed to store soiled linens, and transport linens to prevent the spread of infection. This had the potential to affect all 65 residents whose personal laundry was done at facility.

Inspectors wroteBased on interview and document review the facility failed to allow active resident and resident representative participation in the development and review of care plans for 4 of 4 residents, (R3, R25, R30, R14) reviewed for care planning and coordination of services while residing at the facility.

Inspectors wroteBased on interview and document review, the facility failed to obtain and document an informed consent including explanation of risk and benefits, for 1 of 1 newly admitted resident (R80) reviewed for use of psychotropic medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to follow standards of practice to provide resident education and update the provider for 1 of 1 resident (R33) who routinely refused their diuretic medication.

Inspectors wroteBased on interview and document review the facility failed to communicate with a resident's emergency family contact when they were hospitalized and subsequently discharged from the facility for 1 of 2 residents (R1) reviewed for discharge process.

Inspectors wroteBased on interview and document review the facility failed to ensure a written notice of transfer and bed hold was given to a resident and/or their family upon hospitalization for 1 of 2 residents (R1) reviewed for discharge.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure a self-administration of medications assessment was completed for 1 of 1 resident (R2) observed with medication at their bedside.

Inspectors wroteBased on observation, interview and document review, the facility failed to accommodate resident needs by ensuring call light buttons were within reach for 1 of 2 (R3) residents reviewed for call light usage.

Inspectors wroteBased on interview and document review the facility failed to monitor temperature and intravenous access (IV) site for 1 of 1 resident (R3) following electroconvulsive therapy (ECT).

Inspectors wroteBased on interview and document review, the facility failed to ensure an allegation of potential abuse for 2 of 2 residents (R1, R2) who were involved in a resident-to-resident physical altercation, was reported immediately but no later than 2 hours to the State Agency (SA).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were stored and secured safely in 1 of 1 medication carts observed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 residents (R164) reviewed for dignity.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a call light was accessible for 1 of 3 residents (R164) reviewed for call lights.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food preferences of the resident were honored and implemented for 1 of 2 residents (R24) reviewed for choices.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure a resident was provided the appropriate therapeutic diet and meal supervision for 1 of 1 resident (R164) reviewed for nutrition. Further, the facility failed to ensure a resident was transferred from bed to wheelchair in a manner assessed safe for 1 of 2 residents (R164) observed during transfers.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess and implement interventions to prevent weight loss for 1 of 2 residents (R1). The facility failed to ensure that the resident was set up with assistance for meals and failed to provide a nutritional supplement that was needed to implement interventions to prevent further weight lost for 1 of 2 residents (R1) who had a significant unplanned weight loss.

Inspectors wroteBased on interview and record review the facility failed to ensure a PRN (as needed) psychotropic medication order included an end date for 1 of 1 residents (R16) reviewed for PRN psychotropic medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents with difficulty swallowing were assisted with meals only by qualified individuals.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure proper sanitization of dishware used for meal preparation and resident service when 1 of 1 low-temperature chemical sanitizing commercial dishwashers was identified as not reaching adequate wash and rinse temperatures. This had potential to affect all 62 residents within the facility, staff, and visitors who consumed food from the main production kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure coordination of scheduled and/or follow up appointments was completed for 2 of 3 residents (R38, R47) who required services from outside medical providers, and failed to ensure monitoring for edema (condition where fluid builds up in the body) for 1 of 1 residents (R19) reviewed for edema. Furthermore, the facility failed to ensure medications were administered following standard practice for 1 of 1 resident (R58) reviewed for tube feeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to include individualized approaches for care, including non-pharmacological interventions to aid in the management of behavior, in the comprehensive care plan for 2 of 5 residents (R1, R6) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to identify individualized approaches for care, including non-pharmacological interventions to aid in the management of mood and behavior, for 2 of 5 residents (R1, R27) reviewed for unnecessary medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure appropriate hand hygiene practices were performed following personal cares and catheter care for 1 of 1 resident (R58) observed during cares. In addition the facility failed to ensure enhanced barrier precautions (EBP) were utilized for 1 of 1 resident (R56) reviewed who received dialysis.