Victory Homes I.

“Based on documentation review, observation, and interview the manager failed to ensure there was a means of exiting the facility to control or alert employees of the egress of a resident from the facility. Findings include: 1. Review of the facility documentation revealed the facility is licensed for the Directed level of care.  2. During an environmental inspection of the facility, the Compliance Officer observed that the front door had a deadbolt and an alarm. However, the facility keys were hanging off the deadbolt, and the alarm was not turned on. 3. During an environmental inspection of the facility, the Compliance Officer observed that the sliding back door had an alarm. However, opening the sliding door revealed that the alarm did not alert. 4. During an environmental inspection of a resident's bathroom, the Compliance Officer observed a door leading to the backyard with a deadbolt and alarm. Opening the door revealed it was not locked, and the alarm did not alert. 5. In an interview, E1 acknowledged that the front and back door alarms were turned off and the back door alarm was not functioning properly.”

“Based on record review and interview, the manager failed to ensure that medication administered to a resident was administered in compliance with a medication order. Findings include: 1. A review of R1’s signed medication order dated July 29, 2025, revealed:    Eliquis 5mg 1 tab 2 times daily   Duloxetine HCL 60 mg 1 cap once daily   Gabapentin 300mg 1 cap 3 times daily   Ferrous Sulfate 325mg 1 tab every other day 2. A review of R1’s July 2025 medication administration record (MAR) revealed Duloxetine HCL was not documented as administered.    3. In an interview, E1 acknowledged that Duloxetine HCL was not documented as administered for July but was administered to the resident in compliance with medication orders.”

“Based on observation, record review, and interview, the manager failed to ensure that the medication administered to a resident was documented in the resident's medical record. The Department was provided with false and misleading information. Findings include: 1. During a record review, the Compliance Officer observed the manager walking away with the medication administration folder into another room. 2. A record review of the R1 and R2's medical records revealed medication administration records(MAR) from July 1st to the 30th. 3. In an interview, the Compliance Officer asked E1 if they had filled out the missing MAR. E1 acknowledged R1 and R2 MAR had not been completed since July 15, 2025, and went to the other room to fill out the missing days.”

“Based on observation and interview, the manager failed to ensure that the premises and equipment used at the assisted living facility were free from a condition or situation that could cause a resident or other individual to suffer physical injury. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed a bed frame on the ground, right in front of the sliding back door. 2. During an environmental inspection of the facility, the Compliance Officer observed a door leaning on the glass sliding back door. 3. In an interview, E1 acknowledged that the premises and equipment used at the assisted living facility were free from a condition or situation that could cause a resident or other individual to suffer physical injury.”