Light of Victory Assisted Living LLC

An initial licensure revisit was completed on 10/30/24 for the previous deficiency cited on 9/26/24. A deficiency was cited. Based on observation, record review and interview, the residence failed to be in compliance with all applicable regulations.This failure created the potential for mismanagement of the care of and services for the residents who would be served by this residence.Findings include:-13.1 Double occupancy rooms: a retractable privacy curtain is installed to allow complete visual privacy around each bed that provides a minimum of 60 square feet within the curtain boundaries of each bed.The residence' s undated Resident Rights policy, read in part that residents had the right to privacy. During the environmental tour on 10/30/24 between 10:00 and 12:00 p.m., observations and interviews revealed the residence failed to ensure Room #202 provided a minimum of 60 square feet within the curtain boundaries of each bed. Bed B in Room #202 had access to only 7.5 inches of the only window in the shared room, and would be unable to open the window without physically encroaching on Bed A' s space. With the privacy curtain closed, Bed A measured 52.5 square feet and Bed B measured 48.33 square feet. On 10/30/24 at approximately 10:50 a.m., the administrator confirmed the residence was requesting licensure for 10 beds. She stated Room #202 was designated as double occupancy rooms and had an external contractor review and measure the floor plan and stated she had thought both Bed A and Bed B had met the 60 square foot per room requirement. The administrator further acknowledged she was unaware that both residents had to be able to open the window from their side with the privacy curtains closed. -22.15 Sleeping rooms are 100 square feet for single, 120 square feet for double occupancy.During the environmental tour on 10/30/24 between 10:00 and 12:00 p.m., observations and interviews revealed the residence failed to ensure Room #202 measured at least 120 square feet excluding the closet space and with the privacy curtains open. Room #202 measured 115.7 square feet. On 10/30/24 at approximately 10:50 a.m. T..

An initial certification revisit was completed on 10/30/24 for the previous deficiencies cited on 9/26/24. Deficiences were cited. Based on observation, record review and interview, the setting (residence) failed to ensure the member (resident) had a right to privacy in their living/sleeping units which included a bedroom door with a lock and key, affecting all residents who would be served by this residence. (Cross-reference A410)Findings include:The residence' s undated Resident Rights policy, read in part that residents had the right to privacy. During the environmental tour on 10/30/24 between 10:00 and 12:00 p.m., observations and interviews revealed the residence failed to ensure the design for privacy for residents who would reside in double occupancy rooms including room entrance, windows and other shared common areas was not restricted.Bed B in Room #202 had access to only seven and a half inches of the only window in the shared room, and the resident would be unable to open the window without physically encroaching on Bed A' s space. Further, Bed A measured 52.5 square feet and Bed B measured 48.33 square feet. On 10/30/24 at approximately 10:50 a.m. The administrator stated she was aware of the requirement for double occupancy rooms to measure at least 60 square feet within the privacy curtain and she stated her external contractor had stated both Bed A and Bed B in Room #202 exceeded 60 square feet within the privacy curtain so she had thought the issue was corre.. Based on observation, record review and interview, the setting (residence) failed to ensure the member (resident) had a right to privacy in their living/sleeping units which included a bedroom door with a lock and key, affecting all residents who would be served by this residence. (Cross-reference Q416)Findings include:The residence' s undated Resident Rights policy, read in part that residents had the right to privacy. During the environmental tour on 10/30/24 between 10:00 and 12:00 p.m., observations and interviews revealed the residence failed to ensure the design for privacy for residents who would reside in double occupancy rooms including room entrance, windows and other shared common areas was not restricted.Bed B in Room #202 had access to only seven and a half inches of the only window in the shared room, and the resident would be unable to open the window without physically encroaching on Bed A' s space. Further, Bed A measured 52.5 square feet and Bed B measured 48.33 square feet. On 10/30/24 at approximately 10:50 a.m. The administrator stated she was aware of the requirement for double occupancy rooms to measure at least 60 square feet within the privacy curtain and she stated her external contractor had stated both Bed A and Bed B in Room #202 exceeded 60 square feet within the privacy curtain so she had thought the issue was corre..

An initial licensure survey was completed on 9/26/24. A deficiency was cited. Based on observation, record review and interview, the residence failed to be in compliance with all applicable regulations.This failure created the potential for mismanagement of the care of and services for the residents who would be served by this residence.Findings include:-13.1 Double occupancy rooms: a retractable privacy curtain is installed to allow complete visual privacy around each bed that provides a minimum of 60 square feet within the curtain boundaries of each bed.The residence' s undated Resident Rights policy, read in part that residents had the right to privacy. During the environmental tour on 9/26/24 at approximately 8:00 a.m., observations and interviews revealed the residence failed to ensure Rooms #101, #104, and #202 would provide complete visual privacy for residents who would reside in the double occupancy room and that Room #202 provided a minimum of 60 sqare feet within the curtain boundaries of each bed. a. Privacy curtainThere was no divider for Bed A in both Room #101 and #104, and the divider for Bed B in both Rooms #101 and #104, did not reach around the entire bed area.b. Window Access and Square FeetBed B in Room #202 had access to only 7 inches of the only window in the shared room, and would be unable to open the window without physically encroaching on Bed A' s space. With the privacy curtain closed, Bed A measured 54.59 square feet and Bed B measured 48.13 square feet. On 9/26/24 at approximately 8:00 a.m., the administrator stated the residence was requesting licensure for ten beds. She stated Rooms #101, #104 and #202 were designated as double occupancy rooms, and Room #102, #103, #201 and #203 were designated as single occupancy rooms. She further stated the dividers in Rooms #101 and #104 for Bed A had not yet arrived and acknowledged she was unaware that Bed #A and #B both needed full access to the window in Room #202 without encroaching on one another' s physical space. The administrator further stated she was unaware each double occupancy room must measu..

An initial certification survey was completed on 9/26/24. Deficiences were cited. Based on observation, record review and interview, the setting (residence) failed to ensure the member (resident) had a right to privacy in their living/sleeping units which included a bedroom door with a lock and key, affecting all residents who would be served by this residence. (Cross-reference A410)Findings include:The residence' s undated Resident Rights policy, read in part that residents had the right to privacy. During the onsite visit on 9/26/24 from approximately 7:30 a.m. to 11:00 a.m. with the administrator, the following observations and interviews revealed the residence failed to ensure the design for privacy for residents who would reside in double occupancy rooms including residents' access to toilets, the room entrance, windows and other shared common areas was not restricted.1. Double occupancy roomsa. Room #101There was no divider for Bed A in Room #101, and the divider for Bed B did not reach around the entire bed area.b. Room #104There was no divider for Bed A in Room #104, and the divider for Bed B did not reach around the entire bed area. c. Room #202-basementBed B in Room #202 had access to only seven inches of the only window in the shared room, and the resident would be unable to open the window without physically encroaching on Bed A' s space. On 9/26/24 at approximately 8:00 a.m., the administrator stated the residence was re.. Based on observation, record review and interview, the setting (residence) failed to ensure the member (resident) had a right to privacy in their living/sleeping units which included a bedroom door with a lock and key, affecting all residents who would be served by this residence. (Cross-reference Q416)Findings include:The residence' s undated Resident Rights policy, read in part that residents had the right to privacy. During the onsite visit on 9/26/24 from approximately 7:30 a.m. to 11:00 a.m. with the administrator, the following observations and interviews revealed the residence failed to ensure the design for privacy for residents who would reside in double occupancy rooms including that resident access to toilets, room entrance, windows and other shared common areas was not restricted.1. Double occupancy roomsa. Room #101There was no divider for Bed A in Room #101, and the divider for Bed B did not reach around the entire bed area.b. Room #104There was no divider for Bed A in Room #104, and the divider for Bed B did not reach around the entire bed area. c. Room #202-basementBed B in Room #202 had access to only seven inches of the only window in the shared room, and the resident would be unable to open the window without physically encroaching on Bed A' s space. On 9/26/24 at approximately 8:00 a.m., the administrator stated the residence was re..