A list of the most recent deficiencies for The Village at Victory Lakes. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-22 | 2024-04-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-02-22 | 2024-03-11 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-02-22 | 2024-03-11 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2024-02-22 | 2024-03-07 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-02-22 | 2024-03-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-22 | 2024-03-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-07 | 2024-03-03 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-02-07 | 2024-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-07 | 2024-03-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-07 | 2024-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-07 | 2024-03-03 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-07 | 2024-03-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-07 | 2024-03-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-07 | 2024-03-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-02-07 | 2024-03-03 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2024-02-07 | 2024-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-07 | 2024-03-03 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-02-22 | 2024-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-22 | 2024-02-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-22 | 2024-02-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-03 | 2024-01-19 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-20 | 2023-05-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-05 | 2023-04-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-04-21 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-05 | 2023-04-21 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-04-05 | 2023-04-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-04-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-05 | 2023-04-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-05 | 2023-04-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-04-21 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-07-12 | 2023-04-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-21 | 2022-12-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-15 | 2022-12-27 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-28 | 2022-10-07 | Y |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-07-12 | 2022-08-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-07-12 | 2022-08-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-07-12 | 2022-08-15 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-07-12 | 2022-08-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-07-12 | 2022-08-05 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-07-12 | 2022-08-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-07-12 | 2022-07-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-07-12 | 2022-07-28 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2022-07-12 | 2022-07-28 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2022-07-12 | 2022-07-27 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-07-12 | 2022-07-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-07-12 | 2022-07-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-07-12 | 2022-07-19 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-06-23 | 2022-07-15 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-23 | 2022-07-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-23 | 2022-07-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-23 | 2022-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-23 | 2022-07-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-23 | 2022-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-23 | 2022-07-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-12 | 2022-07-13 | N |
