Inspection Results » Victory Health & Rehabilitation Center

Health Inspection on October 19, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide and implement an infection prevention and control program. (Corrected 2018-12-05)
   • Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. (Corrected 2018-12-05)
   • Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (Corrected 2018-12-05)
   • Implement a program that monitors antibiotic use. (Corrected 2018-12-05)
   • 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. (Corrected 2018-12-05)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Corrected 2018-12-05)
   • Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (Corrected 2018-12-05)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Plan the resident's discharge to meet the resident's goals and needs. (Corrected 2018-12-05)
   • Provide medically-related social services to help each resident achieve the highest possible quality of life. (Corrected 2018-12-05)
   • Notify the resident or the residentÂ’s representative in writing how long the nursing home will hold the residentÂ’s bed in cases of transfer to a hospital or therapeutic leave. (Corrected 2018-12-05)
   • Provide care and assistance to perform activities of daily living for any resident who is unable. (Corrected 2018-12-05)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-12-05)
   • 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. (Corrected 2018-12-05)
   • Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. (Corrected 2018-12-05)
   • Keep residents' personal and medical records private and confidential. (Corrected 2018-12-05)
   • Ensure each resident must receive and the facility must provide necessary behavioral health care and services. (Corrected 2018-12-05)
   • Allow residents to self-administer drugs if determined clinically appropriate. (Corrected 2018-12-05)
   • Provide safe, appropriate pain management for a resident who requires such services. (Corrected 2018-12-05)
   • Provide activities to meet all resident's needs. (Corrected 2018-12-05)
   • Provide safe, appropriate dialysis care/services for a resident who requires such services. (Corrected 2018-12-05)
   • Provide safe and appropriate respiratory care for a resident when needed. (Corrected 2018-12-05)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-12-05)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2018-12-05)
   • Ensure each residentÂ’s drug regimen must be free from unnecessary drugs. (Corrected 2018-12-05)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-12-05)
   • 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. (Corrected 2018-12-05)
   • 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 (Corrected 2018-12-05)
   • Provide appropriate treatment and care according to orders, residentÂ’s preferences and goals. (Corrected 2018-12-05)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2018-12-05)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2018-12-05)
   • 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. (Corrected 2018-12-05)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2018-12-05)

4. Widespread: No actual harm with potential for minimal harm

   • Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. (Corrected 2018-12-05)