Village at Victory Lakes, The

In the surveyor’s words

From the most serious findings on record at Village at Victory Lakes, The, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Mar 12, 2026

  Based on interview and record review the facility failed to immediately identify the code status and initiate Cardiopulmonary Resuscitation (CPR) to a resident (R96) who had elected to be a full code. This failure resulted in an approximate 2 - 4 minute delay in initiating CPR to R96 who was pronounced deceased on [DATE] at the facility. This applies to 1 of 3 residents (R96) reviewed for resident death in the sample of 18. This failure resulted in an Immediate Jeopardy on [DATE] when V5 Certified Nursing Assistant (CNA) found R96 without a pulse or respirations, V5 did not begin CPR, she exited R96's room and went to find V3 Registered Nurse (RN). […]

• Actual harm, isolatedF689May 14, 2026

  Based on observation, interview, and record review, the facility failed to ensure staff used a resident transfer device in a safe manner for 2 of 5 residents (R1, R2) reviewed for safe transfers in the sample of 5. This failure led to R1 being transferred unsafely and dislocating R1's hip.The findings include:R1's Facility Final Report dated 5/8/26 showed on 5/8/26, R1 was being transferred with a assistive transfer device (ATD). R1 was unable to be adjusted safely onto the toilet, was lowered to the floor, and 911 was called to transfer R1 to the hospital.R1's Facility assessment dated [DATE] showed R1 has moderate cognitive impairment. […]

• Actual harm, isolatedF689Feb 23, 2026

  Based on observation, interview and record review the facility failed to ensure a resident (R1) was transported safely in a shower chair. This failure resulted in R1 sustaining a bimalleolar fracture of the right ankle. This affects 1 of 3 residents (R1) reviewed for accidents in the sample of 3. This past non-compliance occurred from 2/11/26 to 2/19/26. The findings include:R1's Facesheet shows R1 has diagnoses that include, but are not limited to: osteoarthritis of the right and left shoulders, atherosclerotic heart disease, history of poliomyelitis, dementia, and chronic kidney disease stage three. R1's Brief Interview for Mental Status dated 2/6/26 shows R1 is cognitively intact.On 2/23/26 at 9:08 AM, R1 had two wheelchair footrests with R1's name written on it. […]

• Actual harm, isolatedF686Jan 29, 2025

  Based on observation, interview, and record review the facility failed to follow the Wound Physician's recommendations, failed to identify, report, and obtain treatment for wounds and failed to provide pressure relieving intervention to prevent the development of pressure ulcers for 4 of 9 residents (R73, R45, R135, R35) reviewed for pressure ulcers in the sample of 20. This failure resulted in R73's MASD-Moisture Acquired Skin Disease to the left and right gluteal area developing into a left gluteal Stage 3 and right gluteal Stage 4 pressure ulcer. The findings include: 1. […]

• Actual harm, isolatedF689Feb 7, 2024

  Based on observation, interview and record review the facility failed to ensure residents were transferred in a safe manner. This failure resulted in R432 being sent to the hospital for 8 days due to increased pain after a transfer. The facility also failed to ensure a resident with a diagnosis of dyspagia was supervised during meals and failed to ensure a resident was provided nectar thick liquids as ordered. This applies to 4 of 18 residents (R5, R7, R44 and R432) reviewed for safety in the sample of 18. The findings include: 1. R432's Face Sheet shows that he originally admitted to the facility on [DATE]. R432's Physical Therapy Evaluation dated 1/8/24 shows that he was referred to therapy for strengthening and decrease level of assistance in bed mobility and transfer. […]