Deficiency Records for Victory Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Victory Health and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-21 | 2024-01-12 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-12-21 | 2024-01-12 | 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 | 2023-12-19 | 2024-01-12 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-06-30 | 2023-08-11 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-30 | 2023-08-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-30 | 2023-08-11 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-06-30 | 2023-08-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-06-30 | 2023-08-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-30 | 2023-08-11 | 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 | 2023-06-30 | 2023-08-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-30 | 2023-08-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-30 | 2023-08-11 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-06-30 | 2023-08-11 | N |
| Provide or obtain dental services for each resident. | Health | 2023-06-30 | 2023-08-11 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-06-30 | 2023-08-11 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-06-30 | 2023-08-11 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-30 | 2023-08-11 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-06-30 | 2023-08-11 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-30 | 2023-08-11 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-27 | 2023-08-11 | 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 | 2023-06-27 | 2023-08-11 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-27 | 2023-08-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-27 | 2023-08-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-27 | 2023-08-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-27 | 2023-08-11 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-06-27 | 2023-08-11 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-27 | 2023-08-11 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-01-13 | 2023-02-20 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-01-13 | 2023-02-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-13 | 2023-02-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-13 | 2023-02-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-13 | 2023-02-20 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-01-13 | 2023-02-20 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-01-13 | 2023-02-20 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-01-13 | 2023-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-13 | 2023-02-20 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-13 | 2023-02-20 | N |
| Perform COVID19 testing on residents and staff. | Health | 2023-01-13 | 2023-02-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-13 | 2023-02-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-13 | 2023-02-20 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-01-10 | 2023-02-20 | 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 | 2023-01-10 | 2023-02-20 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-01-10 | 2023-02-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-01-10 | 2023-02-20 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-01-10 | 2023-02-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-01-10 | 2023-02-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-01-10 | 2023-02-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-10 | 2023-02-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-01-13 | 2023-02-20 | Y |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-01-13 | 2023-02-20 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-01-13 | 2023-02-20 | Y |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-07-18 | 2022-08-30 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-07-18 | 2022-08-30 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-07-18 | 2022-08-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-06-14 | 2022-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-14 | 2022-07-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-06-14 | 2022-07-15 | Y |
| Keep all essential equipment working safely. | Health | 2022-06-14 | 2022-07-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-16 | 2022-06-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-06 | 2022-06-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-06 | 2022-06-10 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-05-06 | 2022-06-10 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-25 | 2022-03-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-02-25 | 2022-03-12 | Y |
| 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 | 2022-02-10 | 2022-03-12 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-02-10 | 2022-03-12 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-02 | 2022-03-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-21 | 2022-02-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-21 | 2022-02-07 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-27 | 2022-01-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-27 | 2022-01-22 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-27 | 2022-01-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-27 | 2022-01-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-27 | 2022-01-22 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-27 | 2022-01-22 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-02 | 2022-01-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-02 | 2022-01-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-02 | 2022-01-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-02 | 2022-01-10 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-12-02 | 2022-01-10 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-12-02 | 2022-01-10 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-02 | 2022-01-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-06 | 2021-09-24 | Y |
| 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 | 2021-08-06 | 2021-09-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-08-06 | 2021-09-24 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-08-06 | 2021-09-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-07 | 2021-08-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-01 | 2021-06-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-19 | 2021-06-14 | Y |
