Victory Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Victory Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Dec 27, 2021

  Based on observation, interview and document review, the facility failed to ensure Centers for Disease Control (CDC) guidelines were followed to prevent or minimize the transmission of COVID-19 for 1 of 5 residents (R4) who were placed on quarantine, though not enforced, following exposure to a COVID-19 positive roommate. This had the potential to affect 54 of 59 residents who had the potential to be exposed to R4 while accessing the communal areas of the facilities. The IJ began on [DATE], at 5:42 a.m. licensed practical nurse (LPN)-A wrote a progress note that she observed R4 in the hallway of the facility. LPN-A explained to R4 that she was on quarantine and should be in her room due to exposure to COVID-19 from a positive roommate. […]

• Immediate jeopardy, isolatedF600May 16, 2022

  Based on interview and document review, the facility failed to prevent abuse of 3 of 3 residents (R1, R2, R3) reviewed for abuse. This resulted in an immediate jeopardy (IJ) when R1, R2, and R3 assaulted one another and the assualts resulted in R1 sustaining a fracture of his left small finger. The IJ began on 4/27/22, when R1 wanted a cigarette from R2. R2 told R1 no, and R1 and R2 had a verbal argument, but were separated by staff. Later the same day, R1 approached R2 and attacked R2, hitting him with his reacher. R2 grabbed a yellow Wet-Floor sign to defend himself, and also used the sign to hit R1. R3 attempted to break up the fight, but was knocked to the ground. Licensed practical nurse (LPN)-A eventually broke up the fight and separated the residents. […]

• Immediate jeopardy, isolatedF578Feb 10, 2022

  Based on observation, interview, and document review, the facility failed to ensure a do-no-resuscitate (DNR) order was accurately reflected throughout the medical record for 1 of 2 residents (R41) reviewed for advanced directives. This resulted in an immediate jeopardy (IJ) for R41 who would had received cardiopulmonary resuscitation (CPR), contrary to their wishes, in the absence of a pulse or respirations. The IJ began on [DATE], at 3:30 p.m. when R1's Provider Orders for Life-Sustaining Treatment (POLST) identified R41 had an active do-not-resuscitate order, however, the electronic health record (EHR) indicated R41's was to be administered CPR. The administrator was notified of the IJ at 3:30 p.m. on [DATE]. The IJ was removed on [DATE], at 10:56 a.m. […]

• Immediate jeopardy, isolatedF689Jun 1, 2021

  Based on observation, interview, and document review, the facility failed to ensure 1 of 1 resident (R2) who was not allowed to have smoking materials did not have access to them. In addition, the facility failed to ensure 1 of 1 resident (R1) who was identified as independent to smoke was smoking in an appropriate area and these smoking practices constituted an Immediate Jeopardy (IJ) for R2 and R1. The IJ began on 5/27/2021, at 8:40 a.m. when R2 and R1 were noted to be smoking in their rooms and the interim director of nursing (DON) and administrator were notified of the IJ on 5/27/21, at 3:30 p.m. The immediate jeopardy was removed on 6/1/21, at 11:50 a.m. after the facility had implemented an acceptable removal plan. […]

• Immediate jeopardy, isolatedF689Jan 25, 2021

  Based on interview and document review, the facility failed to ensure the safety interventions for smoking were implemented for 1 of 6 residents (R1) reviewed for smoking. This failure resulted in an immediate jeopardy (IJ) when R1's cigarette and lighter were not collected from him after smoking, R1 lit a cigarette in his room while on oxygen and sustained facial burns. The facility had implemented corrective action so the deficient practice is being issued at past non-compliance. The IJ began on 1/18/21, at 8:28 a.m. when R1's smoking material was not removed and he sustained [MEDICAL CONDITION] with other items in his room were burned. R1 was hospitalized for [REDACTED]. […]