Deficiency Records for Victory Health and Rehabilitation Center
Updated as of July 01, 2021
This is not the most recent data for Victory Health and Rehabilitation Center. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-02-11 | 2021-03-22 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-02-11 | 2021-03-22 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-02-11 | 2021-03-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-02-11 | 2021-03-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-02-11 | 2021-03-22 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-02-11 | 2021-03-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-02-11 | 2021-03-22 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-02-11 | 2021-03-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-02-11 | 2021-03-22 | N |
| 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 | 2021-02-11 | 2021-03-22 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-02-11 | 2021-03-22 | N |
| Provide activities to meet all resident's needs. | Health | 2021-02-11 | 2021-03-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-11 | 2021-03-22 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-11 | 2021-03-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-02-11 | 2021-03-22 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-02-11 | 2021-03-22 | 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 | 2021-02-11 | 2021-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-02-11 | 2021-03-22 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-02-11 | 2021-03-22 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2021-02-24 | 2021-03-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-02-24 | 2021-03-12 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-01-25 | 2021-02-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-25 | 2021-02-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-01-25 | 2021-02-15 | Y |
| Report COVID19 data to residents and families. | Health | 2021-01-25 | 2021-02-15 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-01-25 | 2021-02-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-01-25 | 2021-01-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-12-23 | 2021-01-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2020-10-20 | 2020-11-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-10-20 | 2020-11-13 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2020-10-20 | 2020-11-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-09-30 | 2020-10-26 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2020-09-30 | 2020-10-26 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2020-09-30 | 2020-10-26 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2020-09-30 | 2020-10-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2020-09-03 | 2020-10-01 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-07-30 | 2020-08-17 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-07-30 | 2020-08-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-06-19 | 2020-08-04 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2020-06-19 | 2020-08-04 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2020-06-19 | 2020-08-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-06-19 | 2020-08-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-19 | 2020-08-04 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-06-10 | 2020-08-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-06-10 | 2020-08-04 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-04-13 | 2020-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-05-20 | 2020-07-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-03-20 | 2020-07-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-02-21 | 2020-03-17 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-11-27 | 2020-03-17 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-27 | 2020-03-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-11-27 | 2020-03-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-12-30 | 2020-01-23 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-12-24 | 2020-01-21 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2019-11-27 | 2020-01-21 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2019-11-27 | 2020-01-21 | 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 | 2019-11-27 | 2020-01-21 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-11-27 | 2020-01-21 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-11-27 | 2020-01-21 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-11-27 | 2020-01-21 | N |
| 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 | 2019-11-27 | 2020-01-21 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2019-11-27 | 2020-01-21 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-11-27 | 2020-01-21 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-27 | 2020-01-21 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-11-27 | 2020-01-21 | N |
| Provide activities to meet all resident's needs. | Health | 2019-11-27 | 2020-01-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-27 | 2020-01-21 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2019-11-27 | 2020-01-21 | N |
| Provide appropriate foot care. | Health | 2019-11-27 | 2020-01-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-11-27 | 2020-01-21 | N |
| Provide appropriate care/assistance for a resident with a prosthesis. | Health | 2019-11-27 | 2020-01-21 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-11-27 | 2020-01-21 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-11-27 | 2020-01-21 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-27 | 2020-01-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-27 | 2020-01-21 | N |
| Provide or obtain dental services for each resident. | Health | 2019-11-27 | 2020-01-21 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2019-11-27 | 2020-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-27 | 2020-01-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-11-27 | 2020-01-21 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-11-27 | 2020-01-21 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-11-27 | 2020-01-21 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-11-27 | 2020-01-21 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-11-27 | 2020-01-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-27 | 2020-01-21 | 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 | 2019-11-27 | 2020-01-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-27 | 2020-01-21 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-27 | 2020-01-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-11-27 | 2020-01-21 | Y |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-11-27 | 2020-01-21 | Y |
| 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 | 2019-11-27 | 2020-01-21 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-11-27 | 2020-01-21 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-19 | 2020-01-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-11-19 | 2020-01-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-19 | 2020-01-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-10-05 | 2019-11-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-10-05 | 2019-11-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2019-10-05 | 2019-11-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-05 | 2019-11-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-05 | 2019-11-12 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-10-05 | 2019-11-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-10 | 2019-05-10 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2019-04-10 | 2019-05-10 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-10 | 2019-05-10 | Y |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2019-04-10 | 2019-05-10 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-10-22 | 2018-12-05 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-22 | 2018-12-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-10-22 | 2018-12-05 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-10-22 | 2018-12-05 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-10-19 | 2018-12-05 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-10-19 | 2018-12-05 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2018-10-12 | 2018-12-05 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2018-10-12 | 2018-12-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-12 | 2018-12-05 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2018-10-12 | 2018-12-05 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-10-19 | 2018-12-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-10-19 | 2018-12-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-19 | 2018-12-05 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-10-19 | 2018-12-05 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-19 | 2018-12-05 | N |
| 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 | 2018-10-19 | 2018-12-05 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-10-19 | 2018-12-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-19 | 2018-12-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-19 | 2018-12-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-19 | 2018-12-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-10-19 | 2018-12-05 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-10-19 | 2018-12-05 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide activities to meet all resident's needs. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-19 | 2018-12-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-19 | 2018-12-05 | N |
| 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 | 2018-10-19 | 2018-12-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-10-19 | 2018-12-05 | 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 | 2018-10-19 | 2018-12-05 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-19 | 2018-12-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-10-19 | 2018-12-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-19 | 2018-12-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-19 | 2018-12-05 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-10-19 | 2018-12-05 | N |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2018-10-19 | 2018-12-05 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-10-19 | 2018-12-05 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-10-19 | 2018-12-05 | Y |
