Inspection visit

Health inspectionSeptember 28, 2023

VICTORIA GARDENS OF ALLENCMS #6758828 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident received services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #93) of 7 residents reviewed for call lights. Residents Affected - Few The facility failed to ensure Resident #93's call button was within reach. This failure could place residents at risk for decreased quality of life, self-worth and dignity. Findings included: Review of the quarterly MDS dated [DATE] revealed Resident # 93 was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses for Resident #93 included: epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures, muscle weakness and atrophy (decrease in size and wasting of the muscle tissue; and diabetes. Review of the MDS revealed Resident # 93 required extensive two-person assistance with ADLs. Resident #93 was incontinent of bowel and bladder. The BIMS score for Resident #93 was 15, indicating that he was cognitively intact. Review of Resident # 93 Care Plan dated 07/24/23 revealed resident requires 2 person assist for ADLS. Resident # 93 was incontinent of bowel and bladder. Resident # 93 had a BIMS of 15 indicating he was cognitively intact. Observation and interview on 09/27/2023 at 12:52PM revealed Resident #93 was lying on his bed. Observation revealed the call light was on the floor near the head of the bed on top of the leg of the bedside table. Interview with Resident #93 revealed he could not find his call light. Observation on 09/27/2023 at 12:58 PM revealed LVN F found the Resident #93's call light on the floor. LVN F picked up the special call light ( a flat white pad call light ) ( off the floor and placed it on resident's bed. Interview with LVN F on 09/27/23 at 01:02 PM revealed the call light had to be within the reach of Resident #93 but she found it on the floor. LVN F stated the resident was not able to use the call light device to request assistance since the call light device was on the floor. LVN F stated the call light had to be always within the reach of the resident. LVN F stated staff were responsible for ensuring call lights were within residents' reach. Interview with LVN C on 09/27/2023 at 01:38 PM revealed a call light must be within the reach of the resident all the time. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 16 Event ID: 675882 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with ADON H on 09/27/2023 at 01:42 PM revealed residents should have their call light device within reach all the time. Interview with the DON on 09/28/2023 at 02:12 PM revealed the call light had to be within the reach of each resident all the time. She stated it was the responsibility of all the staff members to ensure the call light was within the reach of each resident. Review of the facility's policy Answering the call light (Dated March 2021) on 09/28/2023 revealed answering the call light is to ensure timely response to the resident's requests and needs, when the resident is in bed, be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 2 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 (Residents #47 and #93) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to implement a care plan and implement interventions for Resident #47's ADL deficits of hygiene. 2. The facility failed to implement a care plan for Resident #93's specialized call light device. These failures could place residents at risk of not receiving individualized care and services to meet their needs. Findings included: 1. Review of Resident #47's Quarterly MDS assessment, dated 08/25/2023, reflected Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, and cognitive communication deficit. Resident #47 had a BIMS score of 7, which indicated her cognition was severely impaired. Resident#47 required extensive assistance of one-person physical assistance with dressing, transfers, and personal hygiene. Review of Resident #47's Comprehensive Care Plan revised 08/14/23, did not have interventions for Resident #47's personal hygiene. Interview on 09/28/23 at 11:53 AM with MDS Coordinator A revealed the intervention for Resident #47's personal hygiene was missing in the care plan. 2. Review of Resident #93's quarterly MDS assessment dated [DATE] revealed Resident # 93 was a [AGE] year-old male admitted to the facility on [DATE]. The diagnoses for Resident #93 included: epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures); respiratory failure with hypoxia (a serious condition that makes it difficult to breathe on your own. The lungs cannot get enough oxygen into the blood); muscle weakness and atrophy (decrease in size and wasting of the muscle tissue); and diabetes. Review of the MDS revealed Resident # 93 required extensive two-person assistance with ADLs. Resident #93 was incontinent of bowel and bladder. The BIMS score for Resident #93 was 15, indicating that he was cognitively intact. Review of Resident #93's care plan dated 07/24/23 revealed no documentation that Resident #93 required a special call light. Observation and interview on 09/27/2023 at 12:52PM revealed Resident #93 was lying on his bed. Observation revealed the special call light device (flat not click type) was on the floor near the head of the bed on top of the leg of the bedside table. He stated he could not find his call light. Observation on 09/27/2023 at 12:58 PM revealed the LVN F found resident's call light on the floor. LVN F picked up the special call light device and placed it on resident's bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 3 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview with CNA G on 09/28/2023 at 11:30 AM revealed Resident #93 had a special flat call light device. She stated she did not know the reason for Resident #93 to have this special call light device. CNA G stated this special call light device was in resident's room when he got admitted to this room. Interview revealed the previous resident had some issues with his arm in using the regular call light button. Interview with MDS Coordinator A on 09/28/23 at 11:43 AM revealed a special call light must be care planned if the resident was using a special call light device. Observation and interview on 09/28/23 at 11:46 AM revealed the MDS Coordinator reviewing Resident # 93's care plans in the resident medical record on the surveyor's computer. Interview revealed she could not find a care plan reflecting a special call light device for Resident # 93. The MDS Coordinator stated she was primarily responsible to complete the care plan for Resident # 93. The MDS Coordinator stated the interdisciplinary team contributed to care plans. Interview with the DON on 09/28/23 at 2:12 PM revealed the special call light had to be care planned. Interview revealed if Resident #93 had a special call light, then it should be care planed. The DON stated that the MDS Coordinator and Interdisciplinary Team were responsible for developing care plans. Interview revealed the DON was ultimately responsible for care plans. She stated she signed the care plans. Review of the facility's policy Care Plans, Comprehensive Person-Centered revised March 2022 reflected A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident .3. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical .well-being. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 4 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 3 (Resident #9, Resident 47, and Resident #72) of 8 residents reviewed for ADLs. Residents Affected - Some The facility failed to ensure: 1Resident #9 was shaved and not having facial hair. 2Resident #47 had her fingernails cleaned and trimmed. 3Resident #72 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Findings include: 1Review of Resident #9's Quarterly MDS assessment dated [DATE] reflected Resident #9 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses included paraplegia (paralysis of the legs and lower body), muscle weakness, lack of coordination, and type 2 diabetes mellitus. Resident #9 had BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #9 required extensive assistance of one-person physical assistance with dressing, and personal hygiene. Review of Resident #9's Comprehensive Care Plan, revised 03/22/23, reflected the following: Focus: Resident at risk for an ADL self-care performance deficit. Goal: will improve current level of function in mobility, transfers, eating, dressing, toilet use, and personal hygiene through the review date. An observation and interview on 09/27/23 at 10:58 AM revealed Resident #9 was sitting in her wheelchair. She had facial hair on her chin. Resident #9 stated she did not like hair on her face, she stated it was embarrassing, and that she would ask one of the nurses to shave it. 2Review of Resident #47's Quarterly MDS assessment, dated 08/25/2023, reflected Resident #47 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included dementia, muscle weakness, and cognitive communication deficit. Resident #47 had a BIMS score of 7, which indicated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 5 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some her cognition was severely impaired. Resident#47 required extensive assistance of one-person physical assistance with dressing, transfers, and personal hygiene. Review of Resident #47's Comprehensive Care Plan revised 08/14/23, did not address the concern. Observation on 09/27/23 at 9:35 AM revealed Resident #47 was laying in her bed. The nails on both hands were approximately 0.4cm in length extending from the tip of her fingers. The nails were discolored tan, and the underside had dark brown colored residue. Resident #47 was unable to answer questions. 3Review of Resident #72's Quarterly MDS assessment, dated 08/26/2023, reflected Resident #72 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included muscle weakness, hemiplegia (paralysis of one side of the body) affecting right side, cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area). Resident #72 had a BIMS score of 09 which indicated Resident #72's cognition was moderately altered. Resident#72 required extensive assistance of one-person physical assistance with dressing, and personal hygiene. Review of Resident #72's Comprehensive Care Plan revised 09/26/23 reflected the following: Focus: Resident#72 has an ADL self-care performance deficit related to cerebral infarction. Goal: Will maintain current level of function in bed mobility, transfers, eating, dressing, grooming, toilet use and personal hygiene through the review date. Observation and interview on 09/27/23 at 9:39 AM revealed Resident #72 was laying in his bed. The nails on both hands were approximately 0.5cm in length extending from the tip of his fingers. Resident #72 stated that he did not like his nails very long, and he stated he did not tell anybody about his nails. Interview on 09/27/23 at 10:20 AM, CNA I stated CNAs were allowed to cut the residents' nails if they were not diabetic. CNA I stated she would clean and trim Resident #47 and Resident#72's nails right then. Interview on 09/27/23 at 10:45 AM, RN K stated CNAs were responsible to clean and trim residents' nails as needed. RN K stated only nurses cut residents' nails if they were diabetic. RN K stated no one notified her Resident #47, and Resident #72's nails were long and dirty, and she had not noticed the nails herself. Interview on 09/27/23 at 10:58 AM, CNA J stated CNAs were allowed to shave residents' face. CNA J stated she would shave Resident #9's face to remove the hair from Resident's chin. Interview on 09/28/23 9:46 AM, the DON stated nail care should be completed as needed and every time aides wash the residents' hands. The DON stated nails should be observed daily. The DON stated nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON stated she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON stated residents having long and dirty could be an infection control issue. The DON stated CNAs were responsible to shave residents and remove facial hair for female residents, as needed. The DON stated she was responsible to do routine rounds for monitoring. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 6 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's policy titled Fingernails/Toenails, Care of, revised February 2018, reflected Purpose: The purposes of this procedure are to clean the nail bed, to keep nails trimmed, and to prevent infections. 1. Nail care includes daily cleaning and regular trimming . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 7 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice for one (Resident #250) of one resident reviewed for respiratory care in that: Residents Affected - Few RN E failed to follow the procedure for tracheostomy care for Resident #250 when he failed to maintain a sterile/clean field for supplies necessary for care and failed to change his gloves and perform hand hygiene during tracheostomy care when going from dirty to clean multiple times. These failures could place residents with tracheostomies at risk for respiratory infections and the risk of lung infections. Findings include: Review of Resident #250's Face Sheet dated 09/27/23 reflected a [AGE] year-old female with an initial admission date of 08/29/23. Review of Resident #250's comprehensive MDS assessment, dated 09/14/2023, reflected the resident was unable to participate in the interview for cognition. Her active diagnoses included respiratory failure, brain damage, and tracheostomy status. In Section O-Special Treatments, Procedures, and Programs it revealed that she required tracheostomy care (a surgical opening in the neck providing a direct airway through the trachea) and oxygen therapy. Review of Resident #250's Physician orders summary dated 09/27/2023, reflected, .Clean outer trach DRSG QS & PRN .Clean inner cannula QS & PRN . Review of Resident #250's care plan dated 09/06/23, reflected, .resident has a tracheostomy and is at risk for complications .will have no s/sx of infection .ensure trach ties are secure at all times . An observation on 09/26/23 at 03:00 PM revealed RN E entered Resident #250's room to provide tracheostomy care. RN E placed the tracheostomy kit on the resident's bedside table. RN E donned gloves. RN E opened the tracheostomy kit and dumped out all on table except cleaning wand. Cleaning wand was left in tracheostomy kit. RN E poured cleaning liquid into kit where cleaning wand was resting. RN E checked resident oxygen saturation. RN E removed the inner cannula, placed inner cannula in cleaning liquid in tracheostomy kit, and then took cleaning wand and cleaned the inside of the inner cannula. Without removing gloves or performing hand hygiene, RN E put the inner cannula back into place. Without removing gloves or performing hand hygiene, RN E removed the oxygen mask from Resident #250's tracheostomy, removed dirty gauze, replaced with new gauze, and then returned oxygen mask back over tracheostomy site. RN E removed his gloves and washed his hands. In an interview with RN E on 09/26/23 at 3:15 PM, he stated he has been trained one on one regarding tracheostomy care. He stated he was supposed to perform hand hygiene before and after tracheostomy care. He stated he should have removed his gloves and done hand hygiene after cleaning the inner cannula. He stated he knew the procedure was supposed to be an aseptic procedure to reduce the risk of infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 8 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of RN E's 1:1 Trach Education reflected he was in serviced at bedside on 09/13/23 by the Respiratory Therapist. In an Interview with the Respiratory Therapist on 09/27/23 at 10:28 AM revealed that the expectation for tracheostomy care was to clean the bedside table with cleaning wipes and let sit for five minutes. Staff were expected to do hand hygiene before starting care, remove gloves and do hand hygiene during care when going from dirty to clean, and to do hand hygiene after completing care. She stated her trainings were 2.5 to 3 hours in length and she did a one-on-one training with RN E. In an interview with the DON on 09/27/23 at 10:10 AM revealed hand hygiene was to be performed anytime a staff member went from a dirty procedure to a clean procedure or change gloves. She stated RN E received one on one bedside training by the Respiratory Therapist. She stated failure for the staff to follow proper procedures could result in infections. Review of the facility's policy, Tracheostomy Care' revised August 2013, reflected, .Aseptic technique must be used .During cleaning or sterilization of reusable tracheostomy tubes .during all dressing changes until the tracheostomy wound has healed .during tracheostomy tube changes whether reusable or disposable . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 9 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses cart hall 400) of 2 carts reviewed for pharmacy services. The facility failed to ensure LVN C and RN K counted controlled drugs every shift change. This failure could result in an inaccurate controlled medication count, and drug diversion. Findings Included: Record review and random count observation of 400 hall nurse's cart with LVN C on 09/26/2023 at 12:28 PM revealed missing signatures for Off duty and On duty for 08/21/2023, 08/31/2023, 09/02/2023, 09/08/2023 of the narcotic count sheet. Interview on 09/26/2023 at 12:38 PM, LVN C stated he should have signed the narcotic sheet before and after counting the narcotics on 08/31/2023, and 09/08/2023. LVN C stated, I counted the narcotics but forgot to sign. LVN C stated this failure could potentially cause a drug diversion. Interview on 09/26/2023 at 12:45 PM, RN K stated she should have signed the narcotic sheet before and after counting the narcotics on 08/21/2023, and 09/02/2023. RN K stated, I counted the narcotics but forgot to sign because sometimes I get busy. RN K stated this failure could potentially cause a drug diversion. Interview on 09/28/23 at 9:45 AM, the DON stated she expected nurses to sign at the beginning and at the end of their shift after they completed count with the incoming and off-going nurse. The DON stated this was monitored monthly by the pharmacy consultant. The DON stated she had never really had a problem so monitoring more often was not required. The DON stated if the staff was not signing the narcotic count sheets, she was unable to prove they were counting. The DON stated it was important to ensure a drug diversion did not occur. Review of the facility's policy Controlled Substances revised April 2019, reflected the following: .8. Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift 12. At the end of each shift: a. Controlled medications are counted at the end of each shift. The nurse coming on duty and the nurse going off duty determine the count together. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 10 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide liquids consistent with the residents' needs, for one (Resident #85) of three residents reviewed for liquid inconsistency, in that: Resident #85 was not served nectar thickened coffee during her breakfast meal on 09/28/23. This failure could place residents who have dysphagia at risk for aspiration. Findings included: Review of Resident #85's quarterly MDS, dated [DATE], reflected Resident #85 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of coronary artery disease, diabetes, right-sided hemiplegia (paralysis that affects only one side of your body), aphasia (language disorder that affects a person's ability to communicate) and dysphagia. Resident #85 had a BIMS score of 0 indicating she was severely cognitively impaired. Resident #85 had a feeding tube and a mechanically altered diet which specified a required change in texture of food or liquids. The MDS also reflected Resident #85 was extensive assistance with eating with one-person physical assistance. Review of Resident #85's order summary report dated 09/28/23 reflected a diet order, dated 07/20/23, of regular diet mechanical soft texture, nectar consistency for diet. Review of Resident #85's comprehensive care plan dated initiated on 04/03/23 and revised on 05/11/23 reflected, the resident had altered nutritional status due to dysphagia and moderate protein calorie malnutrition. Resident #85 had diet order of nectar thickened liquids. Interventions included to offer diet per orders. Review of Resident #85's Modified Barium Swallowing Study dated 07/18/23 reflected Resident #85 had diagnosis of dysphagia and diet recommendations for Resident #85 were mechanical soft and nectar thick liquids. Observation on 09/28/23 at 9:05 AM revealed Resident #85's meal ticket for breakfast had diet order for mechanical soft and nectar diet. Interview on 09/28/23 at 9:18 AM with CNA D revealed Resident #85 liked to have coffee each morning with her breakfast and she gave her coffee this morning when she brought her tray into resident's room for breakfast. Interview on 09/28/23 at 9:25 AM with the Dietary Manager revealed Resident #85 was on nectar thickened liquids and it was on her meal ticket. She stated Resident #85 got thickened juice on her tray but was not aware of Resident #85 drinking coffee in the morning with her breakfast tray. She stated the coffee pitcher she provided to the hall tray was not thickened. The Dietary Manager stated the kitchen did not provide nectar thickened liquid coffee for Resident #85. She stated coffee was available with the hall trays for dietary staff to give to residents not on thickened liquids. She stated Resident #85 having nectar thickened liquids would need to come from the kitchen on her tray. She stated she would follow-up with Resident #85 to ensure nectar thickened liquids including coffee were provided to her. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 11 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0807 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 09/28/23 at 11:15 AM with the Speech Therapist revealed Resident #85 had a recent swallow study. She stated Resident #85 was on nectar thickened liquids and at risk for silent aspirations. She stated Resident #85 not getting nectar thickened liquids would place her at risk for aspirations and choking risk for resident. She was not aware of Resident #85 getting coffee that was not nectar thickened liquid. Follow-up interview on 09/28/23 at 11:20 AM with CNA D revealed Resident #85 had her thickened juice on the breakfast tray this morning from the kitchen. She stated she poured Resident #85 coffee this morning from the warm pitcher provided for the hall trays. Interview on 09/28/23 at 11:23 PM with LVN F revealed Resident #85 should only get nectar thickened liquids and was at risk for aspirations and choking if resident not provided thickened liquids. Interview on 09/28/23 at 12:09 PM with the DON revealed Resident #85 should have nectar thickened liquids diet as ordered and would place resident at risk for aspirations and choking. Review of facility's policy Dysphagia - Clinical Protocol revised September 2017 reflected The staff and physician will identify individuals with a history of swallowing difficulties or related diagnoses such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food .If a modified consistency or other restrictions are indicated .nursing will obtain an order for such restrictions from Physician. The policy did not reflect about following the physician order for nectar thickened liquids diet. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 12 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain from hospice the most recent hospice plan of care specific to each patient, hospice election form, the physician certification and recertification of the terminal illness specific to each patient and hospice medication information specific to each patient for one (Residents #24) of two residents reviewed for hospice. The facility failed to obtain the required hospice documentation for Resident #24 including hospice election form, the physician recertification of terminal illness, updated hospice plan of care and updated medication list from Hospice O. This failure could result in services and treatments not being coordinated. Findings included: Review of Resident #24's face sheet reflected she was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of cerebral infraction (stroke), chronic obstructive pulmonary disease (chronic inflammatory lung disease that causes obstructed airflow from the lungs), epilepsy (seizure disorder), dementia and heart failure. Review of Resident #24's quarterly MDS assessment dated [DATE] reflected she required extensive assistance with ADLs and indicated she was on hospice services. Review of Resident #24's Physician Order Summary Report reflected a physician order dated 12/02/22 which indicated Resident #24 was admitted to Hospice O for diagnosis of chronic obstructive pulmonary disease. Review of Resident #24's Hospice O book reflected the last Comprehensive Assessment and Plan of Care was dated 02/28/23 which included medication list. Her Hospice O book did not have a hospice election of benefits or physician re-certification/certification of terminal illness. Interview on 09/28/23 at 11:36 AM with LVN C revealed Resident #24 received Hospice O services and Resident #24's hospice documentation was in her hospice O book. Interview on 09/28/23 at 11:55 AM with ADON P revealed she had only been the ADON for about three weeks at the facility. She stated she could not find any other hospice book for Resident # 24. ADON P stated the nurses were responsible for communicating with hospice and if they needed any help, they could reach out to her. Interview on 09/28/23 at 12:05 PM with LVN Treatment Nurse revealed she was the previous ADON. She stated she did not know who the facility's liaison for hospice was. She stated she was not aware of what required hospice documentation the facility needed for residents on hospice services. Interview on 09/28/23 at 12:11 PM with the DON revealed Resident #24' hospice book was missing hospice election of benefits, physician recertification not signed for Resident #24, a current hospice care plan and did not have a current medication profile list. She stated it was important for the facility to have the required hospice documentation for communication and continuity of care for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 13 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents on hospice. She stated social worker was responsible for communicating with hospice and ensuring hospice provided required documentation. Interview on 09/28/23 at 12:37 PM with the Social Worker revealed she contacted hospice company when resident was being admitted to hospice services. She stated she also contacted resident's hospice company to invite to facility's care plan conferences when resident was on hospice services. She was unaware of the required hospice documentation the facility needed for residents on hospice services. She stated she was not aware of until today she was responsible for ensuring residents on hospice services provided the facility with the required hospice documentation on each resident. Review of facility's policy Hospice Program revised July 2017 reflected the Social Worker was designated to coordinate care provided to the resident by out facility staff and the hospice staff .He or she is responsible for the following: .d. Obtaining the following from information from the hospice: (1) the most recent hospice plan of care specific to each resident; (2) hospice election form; (3) physician certification and recertification of the terminal illness specific to each resident .(7) Hospice physician and attending physician (if any) orders specific to each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 14 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 4 (Resident #14, Resident #34, Resident #66, and Resident#69) of 8 residents reviewed for infection control. Residents Affected - Some The facility failed to ensure: 1- RN L disinfected the glucometer in between blood sugar checks for Residents #66 and #69. 2- MA M disinfected the blood pressure cuff in between blood pressure checks for Residents #14 and #34. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: 1- Record review of Resident #66's Quarterly MDS assessment, dated 09/03/23, reflected he was an [AGE] year-old male admitted to the facility on [DATE], with diagnoses including elevated blood pressure, and type 2 diabetes mellitus. He was unable to complete the interview to determine the BIMS. Record review of Resident #66's physician orders dated 09/28/23 reflected Humalog solution 100 unit/ml, inject as per sliding scale: if 71-130 give o unit, 131-180 give 2 unites, 181-240 give 4 unites. Record review of Resident #69's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, and diabetes mellitus. She had a BIMS score of 15 indicating she was cognitively intact. Record review of Resident #69's physician orders dated 09/28/23 reflected, inulin lispro solution 100 unit/ml, inject as per sliding scale: if 1-150 give o unit, 151-200 give 3 unites, 201-250 give 6 unites. Observation on 09/26/23 at 11:50 AM revealed RN L performing blood sugar checks, during which time she checked the blood sugar on Resident #66. RN L did not sanitize the glucometer before or after using it on Resident #66. Observation on 09/26/23 at 11:54 AM revealed RN L performing blood sugar checks, during which time she checked the blood sugar on Resident #69. RN L used the same glucometer right after using it on Resident#66. RN L did not sanitize the glucometer before using it on Resident #69. Interview on 09/26/23 at 11:59 AM, RN L stated reusable equipment, like glucometer, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to bring wipes in her medication cart. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 15 of 16 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675882 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Gardens of Allen 310 S Jupiter Allen, TX 75002 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2- Record review of Resident #14's Quarterly MDS assessment, dated 09/07/23, reflected she was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses including elevated blood pressure, and type 2 diabetes mellitus. She had a BIMS score of 14 indicating she was cognitively intact. Record review of Resident #14's physician orders dated 09/28/23 reflected, metoprolol tartrate 25 mg tablet, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 110, and heart rate less than 60. Record review of Resident #34's Quarterly MDS, dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including elevated blood pressure, and dementia. She had a BIMS score of 15 indicating she was cognitively intact. Record review of Resident #34's physician orders dated 09/28/23 reflected metoprolol tartrate 25 mg tablet, give 1 tablet by mouth two times a day - Special instruction: Hold for systolic blood pressure less than 110, and heart rate less than 60. Observation on 09/27/23 at 7:25 AM revealed MA M performing morning medication pass, during which time she checked the blood pressures on Resident #14. MA M did not sanitize the blood pressure cuff before or after using it on Resident #14. Observation on 09/27/23 at 7:45 AM revealed MA M performing morning medication pass, during which time she checked the blood pressure on Resident #34. MA M used the same blood pressure cuff right after using it on Resident#14. MA M did not sanitize the blood pressure cuff before using it on Resident #34. Interview on 09/27/23 at 7:55 AM, MA M stated reusable equipment, like blood pressure cuffs, should be sanitized with wipes between each resident use (before and after use on each resident) in order to prevent transmitting an infection from one resident to another. She stated she forgot to wipe the cuff this time. Interview on 09/28/23 at 9:45 AM, the DON stated that her expectation was that staff would sanitize all reusable equipment between each resident use. She stated that not doing so placed residents at risk of cross contamination of infections from one resident to another. She said she was responsible for training staff on infection control. She said that she did routine rounds in the floor to ensure the nurses and med aids were following proper infection control procedures. Record review of facility's policy Cleaning and Disinfection of Resident -Care Items and Equipment, revised October 2018, reflected . d. Reusable items are cleaned and disinfected or sterilized between residents. 3. Durable medical equipment must be cleaned and disinfected before reuse by another resident. 4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675882 If continuation sheet Page 16 of 16

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Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0677GeneralS&S Epotential for harm
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
0695GeneralS&S Dpotential for harm
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0807GeneralS&S Dpotential for harm
F807 - Food and drink
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
0849GeneralS&S Dpotential for harm
F849 - Hospice services
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
0880GeneralS&S Epotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.

FAQ · About this visit

Common questions about this visit

What happened during the September 28, 2023 survey of VICTORIA GARDENS OF ALLEN?

This was a inspection survey of VICTORIA GARDENS OF ALLEN on September 28, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at VICTORIA GARDENS OF ALLEN on September 28, 2023?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·September 28, 2023