Village At Victory Lakes, The

Based on interview and record review the facility failed to ensure a resident was free from injury during a shower for 1 of 3 residents (R1) reviewed for falls in the sample of 3.

The findings include:Findings Include:R1's face sheet shows she had diagnoses including artificial hip replacement surgery, difficulty walking, and osteoarthritis of the hip.R1's care plan initiated on 12/17/24 shows she is at risk for falls due to unsteady gait, balance, and decreased strength and endurance.

The care plan also shows she requires partial to moderate assist for showers, dressing, and transfers.

Interventions added on 12/18/24 to R1's care plan to help prevent a fall include keep personal items within easy reach and nursing staff should provide instructions on safety measures. R1's incident note completed by V3 (Licensed Practical Nurse) on 1/7/25 shows that R1 had a fall in the shower room and was very upset. A witnessed fall incident form completed by V3 on 1/7/25 shows that R1 was lying on the floor in the shower room and had a skin tear to her right outer elbow and said she had hit her head and hurt her back during the fall. R1 was sent to a local community hospital for evaluation.R1's hospital records show on 1/7/25 she was brought through the emergency room and complained of head and back pain due to a fall at the facility. R1's hospital records show she received medical tests including X-rays of her knee, hip and spine and scans of her head with no acute findings. R1 was discharged from the emergency room on 1/8/25 and did not return to the facility.On 10/28/25 at 10:25 AM, V4 (Certified Nursing Assistant) said she was in the shower room with R1 when she had a fall on 1/7/25. V4 said she had placed R1's personal items on the top of the heater in the bathroom.

V4 said R1 was still in the shower chair, and she was helping dry R1's legs and back off and R1 mentioned she wanted to have lotion put on. V4 said she turned her back to R1 and went to get her wheelchair to bring it closer to R1 and the next thing she knew the shower chair moved and R1 fell out onto the floor. V4 said she should have handed R1 the lotion or had her seated closer to the items, so she did not have to reach for them. V4 also said sometimes the shower chair will move and R1 was a tall lady so with her having her feet on the floor she thinks that maybe why the chair suddenly moved. V4 said R1 was very upset with her after this incident and would not let her care for her.On 10/28/25 at 11:22, V6 (Registered Nurse) said she was called to the bathroom to assist after R1 fell. V6 said the shower chair can still move at times depending on the resident position so she would not walk away from a resident or turn their back to them in the shower room.The facility provided Fall Prevention and Management Program policy last revised on 1/23/25 shows all staff are responsible to prevent resident falls and care plan interventions including personal items should be kept in their reach should be followed to minimize fall risk.

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.

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