Veterans Victory House

In the surveyor’s words

From the most serious findings on record at Veterans Victory House, in the surveyor’s own words.

• Actual harm, isolatedF600Jan 13, 2022

  Based on interview, record review, and facility policy review, the facility failed to ensure residents were free from abuse for one Resident (R) 155 of four reviewed for abuse in a total sample of 35 residents. Additionally, the facility failed to ensure physician services to provide orders for immediate care and needs for one (R)356 of three reviewed for injuries of unknown origin in a total sample of 35 residents, as evidenced by failing to assess and identify the cause of increased pain and swelling after an unwitnessed fall. […]

• No harm, potential for more than minimal, widespreadF812Feb 21, 2025

  Based on observation, interview, and facility policy review, the facility failed to ensure all items in the freezer and dry storage were sealed, labeled, and dated. The facility also failed to ensure hair coverings were used properly and dishes were clean and allowed to dry before stacking. These failures had the potential to affect all 181 residents in the facility who consumed food from the kitchen. Findings include: Review of the facility's undated policy titled, Employee Sanitary Practices, revealed .Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food . Review of the facility's policy titled, Cleaning Dishes/Dish Machine, undated, revealed, .Allow the dishes to air dry on the dish racks. […]

• No harm, potential for more than minimal, widespreadF812Jan 13, 2022

  Based on observation, interview, and facility policy review, the facility failed to follow food safety requirements by not labeling and dating food items, keeping the refrigerator clean and removing items from the refrigerator by their use by date. This practice had the possibility of negatively affecting all residents in the facility. Findings include: Review of the facility's policy titled, Food Storage dated 2006 stated, Policy: Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored, prepared, and transported at an appropriate temperature and by methods designed to prevent contamination .14. All refrigerator units are kept clean .at all times. 15. Refrigeration: .e. […]

• No harm, potential for more than minimal, patternF804Jan 13, 2022

  Based on record review, observation, interview, and review of Resident Council Minutes the facility failed to provide meals of an appetizing temperature for the residents receiving room trays on three of four units per complaints received through resident council and five of five (Resident (R)6, R155, R35, R110, R147) reviewed for food in a total sample of 35 residents. Findings include: 1. Review of Resident Council minutes dated 10/12/21 revealed in part, Residents asked if both food tray carts must be on the unit before trays can be distributed? Council members suggest that trays be distributed from the first cart to arrive while the kitchen is finishing up trays on the second cart. This way, food trays would be served sooner as they leave the kitchen. […]

• No harm, potential for more than minimal, isolatedF690Jan 19, 2024

  Based on the facility policy titled, Catheter Care (Male), observations and interview, the facility failed to ensure a procedure was followed during Foley catheter care for Resident (R)76, to aid in the prevention of infection. Findings include: Review of the facility policy titled, Catheter Care (Male), states under the procedure: 3. Wash or sanitize your hands. 4. Gather materials (pre-moistened wipes). 5. Set up supplies on barrier. 6. Position the resident for care. 7. Wash or sanitize your hands and apply gloves. 8. Hold shaft of penis (retract foreskin if uncircumcised). 9. Cleanse around one side of the of meatus in a circular motion. Dispose of wipe. 10. Cleanse other side with a new wipe in a circular motion. Dispose of wipe. 11. […]