Village at Victory Lakes, the

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used a resident transfer device in a safe manner for 2 of 5 residents (R1, R2) reviewed for safe transfers in the sample of 5. This failure led to R1 being transferred unsafely and dislocating R1's hip.

Inspectors wroteBased on interview and record review the facility failed to immediately identify the code status and initiate Cardiopulmonary Resuscitation (CPR) to a resident (R96) who had elected to be a full code. This failure resulted in an approximate 2 - 4 minute delay in initiating CPR to R96 who was pronounced deceased on [DATE] at the facility. This applies to 1 of 3 residents (R96) reviewed for resident death in the sample of 18. This failure resulted in an Immediate Jeopardy on [DATE] when V5 Certified Nursing Assistant (CNA) found R96 without a pulse or respirations, V5 did not begin CPR, she exited R96's room and went to find V3 Registered Nurse (RN). V3 and V5 both returned to R96s room and V3 confirmed that R96 was not breathing and did not have a pulse, both staff without starting CPR or calling a code again left R96s room to inform V6 (RN) that R96 had passed away. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that only authorized personnel entered the medication room. This has the potential to affect all the residents residing at the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food was served in a manner to prevent cross contamination. This failure has the potential to affect all 85 residents residing in the facility and receiving food from the kitchen.

Inspectors wroteBased on observation interview and record review the facility failed to ensure a resident was safe during care to 1 of 18 residents (R86) reviewed for safety in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure urinary catheter bags were kept from resting on the floor for 1 of 5 residents (R102) reviewed for catheters in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was weighed upon admission and readmission and failed to verify the accuracy of a resident's weight for a resident with potential for weight loss which applies to 2 of 7 residents (R1, R14) reviewed for weight loss in a sample of 18.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was offered and/or received an influenza vaccination for 1 of 5 residents (R18) reviewed for immunizations in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident (R1) was transported safely in a shower chair. This failure resulted in R1 sustaining a bimalleolar fracture of the right ankle. This affects 1 of 3 residents (R1) reviewed for accidents in the sample of 3. This past non-compliance occurred from 2/11/26 to 2/19/26.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was served the noon meal at the scheduled time. This applies to 1 of 5 residents (R1) reviewed for dietary services in the sample of 5.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was free from injury during a shower for 1 of 3 residents (R1) reviewed for falls in the sample of 3.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the Wound Physician's recommendations, failed to identify, report, and obtain treatment for wounds and failed to provide pressure relieving intervention to prevent the development of pressure ulcers for 4 of 9 residents (R73, R45, R135, R35) reviewed for pressure ulcers in the sample of 20. This failure resulted in R73's MASD-Moisture Acquired Skin Disease to the left and right gluteal area developing into a left gluteal Stage 3 and right gluteal Stage 4 pressure ulcer.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff wore the required PPE (Personal Protective Equipment) in a contact isolation and enhanced barrier precaution room, and failed to ensure gloves were changed during incontinence care to prevent cross contamination. This applies to 4 of 10 residents (R24, R54, R63, R135) reviewed for infection control in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to provide a resident with the bed hold policy when transferring a resident to a hospital for 1 of 2 residents (R23) reviewed for transfers in the sample of 20.

Inspectors wroteBased on interview and record review the facility failed to ensure R36 and R54's PASRR-Preadmission, Screening & Resident Review was reassessed after being newly diagnosed with a mental illness for 2 of 5 residents (R36, R54) reviewed for PASRR in the sample of 20.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner. This failure resulted in R432 being sent to the hospital for 8 days due to increased pain after a transfer. The facility also failed to ensure a resident with a diagnosis of dyspagia was supervised during meals and failed to ensure a resident was provided nectar thick liquids as ordered. This applies to 4 of 18 residents (R5, R7, R44 and R432) reviewed for safety in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure pressure relieving interventions and pressure injury treatments were in place. The facility failed to report a new pressure wound. These failures apply to 4 of 8 residents (R40, R34, R62, R432) reviewed for pressure injuries in the sample of 18.

Inspectors wroteBased on observation interview and record review the facility failed to serve residents the right amount of food to 4 of 4 residents on pureed diets (R38, R433, R62, R12) reviewed for nutritional needs of residents on pureed diets in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure glucometer machines were cleaned in between resident use and failed to ensure Personal Protective Equipment (PPE) was worn appropriately for a resident on contact/droplet isolation for COVID-19 to prevent the spread of infection. This applies to 5 of 18 residents (R16, R434, R182, R8, R432,) reviewed for infection control in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident bed had side rails for bed mobility for 1 of 18 residents (R34) reviewed for accommodation of need in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to provide a written notice of a room change, with rationale, to a resident prior to the resident's room change for 2 of 2 residents (R34 and R7) reviewed for resident rights the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to provide restorative services to residents with limited mobility for 3 of 5 residents (R34, R4, R26) reviewed for restorative services in the sample of 18.

Inspectors wroteBased on interview and record review the facility failed to report a resident's decreased oral intake and failed to identify a resident's severe weight loss. These failures apply to 1 of 5 residents (R4) reviewed for weight loss in the sample of 18.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from medication errors. There were 29 opportunities with 2 errors resulting in a 6.9% medication error rate. This applies to 2 of 10 residents (R26 and R434) reviewed for medication administration in the sample of 18.

Inspectors wrote2. R434's Face Sheet shows diagnoses of: diabetes mellitus. R434's Medication Administration Record shows an order for Novolog FlexPen-Inject 5 units subcutaneously with meals and an order for Novolog FlexPen as per sliding scale: 200-249=4 units. On 2/5/24 at 11:46 AM, V3 (Registered Nurse) performed a blood sugar check on R434 and her blood sugar was 214. V3 prepared a Novolog Insulin Pen to administer R434 her ordered insulin. V3 put the needle onto the pen and dialed the pen to 9 units and administered the insulin. V3 did not prime the pen before administering the insulin. On 2/5/24 at 12:27 PM, V3 stated, Insulin pens should be primed with one unit before giving, I think. On 2/6/24 at 11:27 AM, V7 (Registered Nurse) said that insulin pens should be primed with 2 units before administered the insulin to ensure that the resident receives the ordered dose of insulin. [...]

Inspectors wroteBased on interview and record review the facility failed to provide specialized rehabilitation services, including speech therapy (ST), physical therapy (PT), and occupational therapy (OT), to a resident for 1 of 13 residents (R5) reviewed for skilled therapy services in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess and identify a resident's pressure injury to her right lower leg until it was a stage 3 acquired pressure injury from a medical device. This applies to 1 of 3 residents (R2) reviewed for acquired pressure injuries in the sample of 3. This resulted in R2 sustaining a facility acquired stage 3 pressure injury.