Victoria Gardens of Allen

In the surveyor’s words

From the most serious findings on record at Victoria Gardens of Allen, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 3, 2022

  Based on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents and hazards for 1 of 2 resident reviewed (Resident #1) in that: The facility failed to ensure Resident #1 received the proper staff supervision during transport from [CONDITION(S)] treatment. Resident #1 was left in the facility van alone without ventilation from windows, no air conditioning, strapped in her wheelchair with seatbelt over her chest for approximately 20-30 minutes in 98 degrees outside weather. She stated she had been yelling and screaming, then beating on the window to get someone's attentions. […]

• No harm, potential for more than minimal, widespreadF812Dec 16, 2021

  Based on observation, interview and record review the facility failed to store, prepare and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure sanitary practices were maintained in the kitchen pertaining to the dish machine temperature. These failures could place residents who eat from the kitchen at risk for cross-contamination and food-borne illness. Findings include: Review of the Dish Machine Temperature and Chemical Log, dated December 2021, revealed the dish machines was to be checked for appropriate temperature and chlorine every day at breakfast, lunch, and dinner. The log had no documentation from 12/06/21 at dinner through 12/16/2021 at breakfast. […]

• No harm, potential for more than minimal, patternF812Jun 28, 2026

  Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety 1 of 1 kitchen. 1. The facility failed to ensure food items were labeled and dated in the walk-in refrigerator.2. The facility failed to ensure expired food items were not in the walk-in refrigerator.3. The Dietary Manager failed to ensure lunch food temperatures were checked on the steam table line. These failures could place residents at risk of food contamination and food-borne illness.Findings included: During an observation on 06/28/26 at 9:12 AM, the following food items were observed in the walk-in refrigerator:Undated and unlabeled hamburger patties in an aluminum container;2 pounds of undated Sliced Smoke… […]

• No harm, potential for more than minimal, patternF645Feb 11, 2026

  Based on interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 2 residents (Resident #8), reviewed for resident assessment.Resident #8's PASRR level 1 screening form did not reflect mental illness, and the resident did not have a PASRR level II evaluation .This could place residents at risk of not receiving necessary specialized services to meet their individual needs.The findings were:Record review of Resident #8's quarterly MDS assessment, dated 01/15/2026, reflected the resident was a [AGE] year-old female admitted to the facility on [DATE]. The resident's BIMs score was 15 indicating the resident's cognition was intact. […]

• No harm, potential for more than minimal, patternF689Jan 20, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 9 rooms (Rooms 104, 105, 108, 209, 212, 306, 307, and 312) of 30 rooms reviewed for accident hazards. The facility failed to ensure the needle sharps containers (which are specialized receptacles designed to safely dispose of sharp medical instruments that can cause injuries or infections) in Rooms 104, 105, 108, 209, 212, 306, 307, and 312 were emptied.This failure could place residents at risk of being injured by a needle, and exposure to bloodborne pathogens. Findings included: Observation on 01/20/26 from 10:00 AM to 11:00 AM revealed all resident rooms have a sharps container mounted inside the resident room by the door. […]