Inspection Reports for Victoria Gardens of Allen
310 S Jupiter Rd, Allen, TX 75002, TX, 75002
Back to Facility ProfileInspection Report Summary
The most recent inspection on December 7, 2024, identified deficiencies related to improper storage of respiratory equipment and lapses in infection prevention and control practices. Earlier inspections showed a pattern of issues with resident care, including delayed incontinence and wound care, as well as infection control and respiratory care concerns. Inspectors cited problems with timely care delivery, documentation discrepancies, and failure to follow hygiene protocols. Several complaint investigations were substantiated, particularly regarding respiratory care, infection control, and wound care, but no fines or enforcement actions were listed in the available reports. The facility’s inspection history indicates ongoing challenges in infection control and resident care, with recent findings consistent with prior issues.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
149% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 7, 2024
Visit Reason
The inspection was conducted due to complaints regarding respiratory care and infection control practices at the facility, specifically concerning the proper storage of respiratory equipment and adherence to infection prevention protocols.
Complaint Details
The complaint investigation found that the facility failed to provide safe respiratory care and maintain infection control practices, specifically improper storage of respiratory equipment for Residents #1 and #2, and inadequate hand hygiene and glove use by CNA B during care for Resident #2.
Findings
The facility failed to ensure proper storage of respiratory equipment for two residents, risking respiratory infections. Additionally, the facility failed to maintain an effective infection prevention and control program, as a CNA did not perform proper hand hygiene and glove changes during incontinent care, risking cross-contamination and infection.
Deficiencies (3)
Failure to ensure Resident #1's breathing mask for nebulization was properly stored.
Failure to ensure Resident #2's nasal cannula was properly stored.
Failure to maintain an infection prevention and control program; CNA did not change gloves or perform hand hygiene properly during incontinent care for Resident #2.
Report Facts
Residents reviewed for Respiratory Care: 5
Residents reviewed for Infection Control: 5
BIMS score Resident #1: 15
BIMS score Resident #2: 13
Physician order frequency: 4
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in infection control deficiency for improper glove use and hand hygiene during incontinent care. |
| RN A | Registered Nurse | Observed and corrected improper storage of respiratory equipment for Residents #1 and #2. |
| Administrator | Interviewed regarding expectations for respiratory care and infection control; planned staff in-service. | |
| DON | Director of Nursing | Interviewed regarding respiratory care and infection control expectations; planned staff re-education and monitoring. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 20, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely incontinence care and appropriate pressure ulcer wound care for residents.
Complaint Details
The complaint investigation revealed substantiated issues with delayed incontinence care for Resident #81 and missed wound care treatments for Resident #8, with interviews and record reviews supporting these findings.
Findings
The facility failed to provide timely incontinence care to Resident #81 on 11/17/24, resulting in the resident sitting in a wet brief for over an hour. Additionally, the facility failed to provide wound care to Resident #8 on 11/16/24 and 11/17/24, with documentation discrepancies and resident reports indicating missed treatments over the weekend.
Deficiencies (2)
Failure to provide Resident #81 with timely incontinence care on 11/17/24.
Failure to provide wound care for Resident #8 on 11/16/24 and 11/17/24.
Report Facts
Residents reviewed for ADL care: 8
Residents reviewed for pressure ulcers: 3
Time resident waited for incontinence care: 105
Pressure wound dimensions: 13.45
Pressure wound length: 6.12
Pressure wound width: 2.65
Pressure wound area: 23.8
Pressure wound width: 7
Pressure wound depth: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in relation to delayed incontinence care for Resident #81 on 11/17/24. | |
| LVN B | Licensed Vocational Nurse | Answered call light for Resident #81 and responsible for ensuring timely incontinence care. |
| DON | Director of Nursing | Interviewed regarding staff knowledge and actions related to Resident #81's care and wound care documentation. |
| Nurse #1 | Charge Nurse, LVN | Responsible for wound care and documentation for Resident #8; worked weekends only. |
| Nurse #2 | Provided wound care for Resident #8 on 11/15/24 and 11/18/24. | |
| ADON | Assistant Director of Nursing / Wound Care Nurse | Performed wound care observation and interviewed regarding wound care for Resident #8. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 20, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely incontinence care and appropriate pressure ulcer care to residents.
Complaint Details
The complaint investigation revealed that Resident #81 had to wait an hour and forty-five minutes for incontinence care on 11/17/24, and Resident #8 did not receive wound care on 11/16/24 and 11/17/24. The Director of Nursing (DON) and other staff were interviewed regarding these issues. The DON was not aware of the documentation lapses and believed Resident #8 received wound care despite resident reports to the contrary.
Findings
The facility failed to provide timely incontinence care to Resident #81 on 11/17/24, resulting in the resident sitting in a wet brief for an extended period. Additionally, the facility failed to provide wound care for Resident #8 on 11/16/24 and 11/17/24, which could lead to worsening of pressure ulcers and increased risk of infection.
Deficiencies (2)
Failure to provide Resident #81 with timely incontinence care on 11/17/24.
Failure to provide wound care for Resident #8 on 11/16/24 and 11/17/24.
Report Facts
Residents reviewed for ADL care: 8
Residents reviewed for pressure ulcers: 3
BIMS score: 15
BIMS score: 14
Pressure wound dimensions (cm): 13.45
Pressure wound dimensions (cm): 6.12
Pressure wound dimensions (cm): 2.65
Pressure wound dimensions (cm): 23.8
Pressure wound dimensions (cm): 7
Pressure wound dimensions (cm): 3
Time waited for incontinence care: 105
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Named in relation to delayed incontinence care for Resident #81. | |
| LVN B | Licensed Vocational Nurse | Answered call light for Resident #81 and responsible for ensuring timely incontinence care. |
| DON | Director of Nursing | Interviewed regarding the incidents and staff responsibilities. |
| Nurse #1 | Charge Nurse, LVN | Responsible for wound care and documentation for Resident #8; worked weekends only. |
| Nurse #2 | Provided wound care for Resident #8 on 11/15/24 and 11/18/24. | |
| ADON | Assistant Director of Nursing / Wound Care Nurse | Performed wound care observation and interviewed regarding wound care documentation. |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jan 5, 2024
Visit Reason
The document is an annual inspection report for Victoria Gardens of Allen, conducted as a routine regulatory survey to assess compliance with health and safety standards.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Dec 7, 2023
Visit Reason
The inspection was conducted as a routine annual survey of the nursing home facility Victoria Gardens of Allen to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Nov 15, 2023
Visit Reason
The inspection was conducted as a routine annual survey of Victoria Gardens of Allen to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 8
Date: Sep 28, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, infection control, pharmaceutical services, hospice services, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach, incomplete care plans, inadequate assistance with activities of daily living, improper respiratory care, failure to count controlled substances properly, failure to provide thickened liquids as ordered, missing hospice documentation, and inadequate infection prevention and control practices.
Deficiencies (8)
Failed to ensure Resident #93's call button was within reach.
Failed to develop and implement comprehensive person-centered care plans for Residents #47 and #93.
Failed to provide necessary services for residents unable to perform ADLs for Residents #9, #47, and #72.
Failed to provide appropriate respiratory care for Resident #250, including aseptic technique during tracheostomy care.
Failed to ensure controlled drugs were counted and signed for every shift change on Nurses cart hall 400.
Failed to provide nectar thickened liquids as ordered for Resident #85, specifically nectar thickened coffee.
Failed to obtain required hospice documentation for Resident #24 including hospice election form, physician recertification, updated hospice plan of care, and medication list.
Failed to maintain infection prevention and control program by not disinfecting glucometer and blood pressure cuff between resident uses for Residents #14, #34, #66, and #69.
Report Facts
Residents reviewed for call lights: 7
Residents reviewed for comprehensive care plans: 24
Residents reviewed for ADLs: 8
Residents reviewed for respiratory care: 1
Nurses carts reviewed for pharmacy services: 2
Residents reviewed for liquid consistency: 3
Residents reviewed for hospice services: 2
Residents reviewed for infection control: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN F | Licensed Vocational Nurse | Found Resident #93's call light on the floor and stated call light must be within reach. |
| LVN C | Licensed Vocational Nurse | Counted controlled drugs but failed to sign narcotic count sheets on multiple dates. |
| RN K | Registered Nurse | Counted controlled drugs but failed to sign narcotic count sheets on multiple dates. |
| RN E | Registered Nurse | Failed to follow aseptic technique during tracheostomy care for Resident #250. |
| CNA D | Certified Nursing Assistant | Provided coffee not nectar thickened to Resident #85. |
| MA M | Medication Aide | Failed to disinfect blood pressure cuff between residents. |
| RN L | Registered Nurse | Failed to disinfect glucometer between residents. |
| ADON P | Assistant Director of Nursing | Could not find hospice documentation for Resident #24. |
| LVN Treatment Nurse | Licensed Vocational Nurse | Unaware of required hospice documentation for residents on hospice. |
| DON | Director of Nursing | Provided multiple interviews regarding call light responsibility, controlled substance counts, infection control, and hospice documentation. |
| Speech Therapist | Confirmed Resident #85 required nectar thickened liquids and risk of aspiration. | |
| Respiratory Therapist | Provided one-on-one training to RN E on tracheostomy care. | |
| CNA G | Certified Nursing Assistant | Reported Resident #93 had a special flat call light device. |
| CNA I | Certified Nursing Assistant | Stated CNAs were allowed to cut nails for non-diabetic residents. |
| RN K | Registered Nurse | Stated CNAs were responsible for nail care except for diabetic residents. |
| CNA J | Certified Nursing Assistant | Stated CNAs were allowed to shave residents' faces. |
| Dietary Manager | Reported kitchen did not provide nectar thickened coffee for Resident #85. | |
| Social Worker | Unaware of responsibility to ensure hospice documentation for residents on hospice. |
Inspection Report
Deficiencies: 1
Date: Jul 20, 2023
Visit Reason
The inspection occurred to evaluate the safety of the nursing home environment, specifically focusing on oxygen storage safety in the facility.
Findings
The facility failed to securely store oxygen cylinders in one of four hallways observed, with one free-standing oxygen cylinder found unsecured in a resident room, posing a risk of injury due to the combustible nature of oxygen cylinders.
Deficiencies (1)
Failed to securely store oxygen cylinders in room [ROOM NUMBER], with one free-standing oxygen cylinder without a rack, chain, or strap.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN | Interviewed regarding unsecured oxygen cylinder observation | |
| Administrator | Interviewed regarding oxygen cylinder storage requirements |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 13, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including accommodation of resident needs and preferences, and the development and implementation of comprehensive care plans.
Findings
The facility failed to ensure Resident #1's customized manual wheelchair was repaired and that follow-up was provided regarding its status, potentially impacting resident quality of life. Additionally, the facility failed to develop a comprehensive care plan addressing Resident #2's right sided limited range of motion, risking inadequate care provision.
Deficiencies (3)
Facility failed to ensure Resident #1 had her customized manual wheelchair fixed and did not follow up with Resident #1 about the customized manual wheelchair repairs.
Facility failed to ensure the comprehensive care plan described the services to attain or maintain Resident #2's highest practicable physical, mental, and psychosocial well-being, specifically failing to address Resident #2's right sided limited range of motion.
Review of facility's Customized power wheelchair policy undated did not address customized manual wheelchairs.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Interviewed regarding Resident #1's customized wheelchair and Resident #2's right sided limitation. | |
| Director of Rehab | Interviewed about Resident #1's customized wheelchair and follow-up with vendor. | |
| OT B | Occupational Therapist | Interviewed about Resident #1's customized wheelchair and Resident #2's hemiplegia and transfer assistance. |
| PT C | Physical Therapist | Interviewed about awareness of Resident #1's customized wheelchair being broken. |
| CNA D | Certified Nursing Assistant | Interviewed about Resident #1's customized wheelchair and Resident #2's assistance needs. |
| Maintenance Director | Interviewed about Resident #1's customized wheelchair repair and follow-up. | |
| Administrator | Interviewed about awareness and expectations regarding Resident #1's customized wheelchair status and follow-up. | |
| MDS Coordinator | Interviewed about Resident #2's care plan and documentation responsibilities. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 3, 2023
Visit Reason
The inspection was conducted due to a complaint regarding inadequate supervision and assistance devices to prevent accidents, specifically related to a resident who slid out of her wheelchair while being transported in the facility van.
Complaint Details
The complaint investigation revealed that Resident #1 slid out of her wheelchair while being transported in the facility van by the Administrator, who was not a CNA and was driving without a CNA accompanying him as required. The resident reported not having a seatbelt on during the incident, though the Administrator denied this. The resident was assessed with no injuries. The Administrator had been driving the van since June 8, 2023, without a CNA present. Facility policy requires all drivers transporting residents to be certified nurse aides, certified medication aides, or licensed nurses.
Findings
The facility failed to ensure Resident #1 was adequately secured in her wheelchair during transport, resulting in the resident sliding out of her wheelchair on a slippery lift pad in the van. The Administrator was driving the van without a CNA present, contrary to facility policy requiring certified staff for transport. No injuries were reported, but the failure posed a risk of harm to residents.
Deficiencies (1)
Failure to ensure residents received adequate supervision and assistance devices to prevent accidents during transport, specifically Resident #1 not being adequately secured in her wheelchair in the facility van.
Report Facts
Date of incident: Jun 28, 2023
BIMS score: 11
Date of van driver hire: Jun 8, 2023
Date of training: Mar 10, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Administrator | Driver of the van during the incident, responsible for ensuring staff met requirements |
| RN A | Registered Nurse | Conducted interview with Resident #1 on 6/28/23 |
| ADON | Assistant Director of Nursing | Assessed Resident #1 after incident and assisted with getting resident back into wheelchair |
| Maintenance | Maintenance Staff | Assisted with Resident #1 after incident |
Inspection Report
Deficiencies: 1
Date: May 4, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards regarding clinical record maintenance and documentation of wound care treatments.
Findings
The facility failed to maintain complete and accurate clinical records for one resident, specifically failing to document wound care treatments on four dates in April 2023, which could place residents at risk for incomplete medical records.
Deficiencies (1)
Failure to document wound care treatments on Resident #1's Treatment Administration Record for 04/08/23, 04/09/23, 04/15/23, and 04/16/23.
Report Facts
Residents reviewed for clinical records: 8
Dates of undocumented wound care: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in wound care documentation deficiency |
| DON | Director of Nursing | Provided interview regarding documentation expectations and deficiencies |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on compliance with hand hygiene and wound care procedures for residents.
Findings
The facility failed to maintain an adequate infection prevention and control program, as evidenced by an LVN's failure to perform hand hygiene between glove changes during wound care for one resident. This posed a risk for the spread of infection. Facility policies on wound care and hand hygiene were reviewed and found to emphasize the importance of hand hygiene, which was not consistently followed.
Deficiencies (1)
Failure to perform hand hygiene and between glove changes while providing wound care for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Licensed Vocational Nurse | Named in deficiency for failing to perform hand hygiene between glove changes during wound care. |
| ADON | Acting Director of Nursing | Provided interview statements regarding proper hand hygiene procedures during wound care. |
Inspection Report
Routine
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically focusing on compliance with hand hygiene and wound care procedures for residents.
Findings
The facility failed to maintain an adequate infection prevention and control program, as evidenced by an LVN not performing hand hygiene between glove changes during wound care for one resident. This failure posed a minimal harm risk to residents by potentially spreading infections. Facility policies on wound care and hand hygiene were reviewed and found to emphasize proper hand hygiene practices, which were not followed during the observed care.
Deficiencies (1)
Failure to perform hand hygiene and between glove changes while providing wound care for Resident #1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Named in deficiency for failing to perform hand hygiene between glove changes during wound care. | |
| ADON | Acting Director of Nursing | Provided interview statements regarding proper hand hygiene practices during wound care. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 17, 2022
Visit Reason
The inspection was conducted due to concerns about sanitary conditions in the facility's kitchen, specifically regarding food storage, preparation, and serving practices.
Complaint Details
The visit was complaint-related, focusing on food safety and sanitary practices in the kitchen. The complaint was substantiated with findings of expired products and improper hair restraints.
Findings
The facility failed to maintain sanitary food handling practices, including staff wearing inappropriate hair restraints, use of expired lemon juice, and undated seasoning containers, which could place residents at risk for foodborne illnesses.
Deficiencies (3)
Dietary staff wore hair restraints from home that did not fully cover hair while working in the kitchen.
Seasoning containers used to prepare food lacked dates opened or expiration dates.
Expired lemon juice was found in the food preparation area and dry storage room.
Report Facts
Expired lemon juice bottles: 3
Undated seasoning bottles: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Aide-B | Dietary Aide | Observed washing dishes wearing a spandex black hat with hair exposed in the back. |
| DM | Dietary Manager | Interviewed regarding expired lemon juice and undated seasonings; responsible for monitoring food safety practices. |
| LD | Laboratory Director | Interviewed about hair restraint policies and sanitary practices in the kitchen. |
| DA-D | Dietary Aide | Interviewed about facility policy on hair restraints and sanitary practices. |
| DA-A | Dietary Aide | Interviewed about hair restraint training and awareness of expired lemon juice and undated seasoning. |
| CO-E | Cook | Interviewed about hair restraint use and checking expiration dates on seasonings and lemon juice. |
| CO-G | Cook | Interviewed about hair restraint use and checking expiration dates on seasonings and lemon juice. |
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