Victoria Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 6 and 51) Minimum Data Set (MDS- standardized assessment and care planning tool) reflected an accurate assessment by failing to: a. Ensure Resident 51, who was discharged to home under the care of home health (wide range of health care services that can be given at home for an illness or injury) service was coded in the MDS assessment accurately.b. Ensure Resident 6's hearing impairment was coded in MDS assessment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans to meet the residents' needs for three of three sampled residents (Residents 6, 31 and 38) by failing to: a. Implement Resident 31's care plan of turning and repositioning schedule every two (2) hours. b. Developed a care plan to address Resident 6's hearing loss and use of Gabapentin (a medication for nerve pain and used to control seizures). c. Developed a care plan to address Resident 38's current gastrostomy tube (GT, a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications) feeding formula. These failures had the potential for Residents 6, 31, and 38 not to receive necessary care, treatment, and services specific to their needs.

Inspectors wroteBased on interview and record review, the facility failed to revise the care plans (CP) for two of two sampled residents (Residents 7 and 10) when:a. Resident 7's gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach) tube was removed.b. Resident 10 did not take medication for edema (swelling caused when extra fluid leaked from blood vessels and collected in body tissues). These deficient practices had the potential for Residents 7 and 10 to not receive appropriate care, treatment and/or services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for residents receiving oxygen therapy (treatment that provided extra oxygen) in accordance with professional standards of practice for two of the two sampled residents (Residents 8 and 10) by failing to: a. Ensure Resident 10's nasal cannula tubing (a flexible plastic tubing used to deliver oxygen through the nostrils), oxygen humidifier (a small bottle that adds moisture to oxygen), and oxygen storage bag (a plastic bag that stores oxygen supplies for a resident) were properly labeled.b. Ensure Resident 8's nasal cannula tubing, oxygen humidifier, and oxygen storage bag were properly labeled. These failures placed Residents 8 and 10 at risk of complications related to the use of oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to post the actual nurse staffing information at the beginning of each shift in a prominent location readily accessible to residents, visitors, and staff for viewing for two of three recertification survey days (4/7/2026 and 4/8/2026). These failures had the potential to mislead the residents, visitors, and staff of the actual staffing in the facility that may affect the quality of nursing care provided to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe food storage and handling practices in two of two facility kitchen refrigerators (Refrigerators 1 and 2), by failing to:a. Label a tray with four (4) heads of lettuce in Refrigerator 1 with received date.b. Discard an open plastic container of 2% milk, around one-fourth (1/4) full, past its use-by-date (relating to food safety) in Refrigerator 2.c. Discard an open plastic container of prune juice, around half (1/2) full, past its use-by-date in Refrigerator 2. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (an alerting device to assist a resident when needed) was within reach for one of one sampled resident (Residents 45). This failure had the potential to delay meeting Resident 45's needs or result in a fall or accident/injury.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to elevate the resident's head of the bed (HOB) while the resident was receiving formula through the gastrostomy tube (GT - a tube inserted through the abdomen that delivers nutrition/medication directly into the stomach) in accordance with the resident's care plan and physician's order for one of three sampled residents (Resident 32). This deficient practice had the potential to result in aspiration (inhalation of foreign materials) and respiratory complications for Resident 32.

Inspectors wroteBased on interview and record review, the facility failed to ensure medication regimen review (MRR) irregularity identified by the facility's Pharmacy Consultant was acted upon for one of five sampled resident (Resident 5) in accordance to facility's policy and procedure Consultant Pharmacist Report. This deficient practice had the potential for harm due to the missed opportunity by the physician and the licensed staff to act upon the reported irregularities for Resident 5.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a minimum of 80 square feet (sq. ft., unit of measurement) per resident area for twelve (12) out of thirteen (13) resident rooms (Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14). This deficient practice had the potential to impact the ability to provide safe nursing care and privacy to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate assessment was conducted for one of one sampled resident (Resident 1). Resident 1 did not have an accurate assessment for the resident's cognitive skills for daily decision making. This deficient practice resulted in inaccurate assessment for Resident 1's elopement risk and had the potential for delay in necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment for two of three sampled residents (Resident 1 and Resident 2), as indicated in the facility's policy and procedures (P&P) titled, Accidents and Supervision, and Resident Right to Access and Visitation, by failing to ensure: 1. There was adequate resident visitation monitoring (continuous observation) at the facility's main front door entrance during the night shift (11 PM to 7 AM). This failure resulted in an unknown visitor walking inside the facility without staff awareness and entering Resident 1' and Resident 2's room. The failure had the potential to result in physical, emotional, and mental harm for Resident 1, Resident 2, and other residents residing at the facility. Findings 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directive (AD, a legal document indicating resident preference on end-of-life treatment decisions) was discussed and written information was provided to the resident and/or responsible party and a current copy of the AD was in the medical chart for two of two sampled residents (Residents 145 and 5), consistent with the facility's policy and procedure on AD. These failures had the potential for facility staff to provide medical treatment and services against the residents' will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to administer oxygen as ordered and in accordance with the facility's Policy and Procedure (P&P) on oxygen administration for two of two sampled residents (Residents 3 and 193). These failures had the potential to result in adverse consequences for Residents 3 and 193.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its Policy and Procedure (P&P) on the use of bed rails/siderails (adjustable metal or rigid plastic bars attached to the bed) and grab bars (bars installed on the side of the bed) for two of two sampled residents (Residents 145 and 9). These failures placed Residents 145 and 9 at risk for entrapment (an event in which resident was caught, trapped, or entangled in the tight spaces around the bed) and injury from the use of siderails and grab bars.

Inspectors wroteBased on interview and record review, for two of five sampled residents (Residents 10 and 94), the facility failed to ensure: a. Resident 94's physician order for Lorazepam (medication used to treat anxiety disorders [a condition that involves excessive fear, worry, or dread that interferes with daily life]) had a stop date as indicated in the facility's policy and procedures (P&P) on the use of psychotropic medication (drugs that alter the brain chemistry and affect metal processes, emotions and behavior). b. Resident 10's target behavior was monitored for the use of Haloperidol (antipsychotic medication to treat serious mental disorder in which people interpret reality abnormally) as indicated in the facility's P&P on the use of psychotropic medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and sanitary environment to prevent the development and transmission of communicable diseases (one that is spread from one person to another) for two of five sampled residents (Residents 145 and 2) by failing to: a. Ensure Certified Nurse Assistant 3 (CNA 3) wore the required Personal Protective Equipment (PPE, clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) when providing care to Resident 145 who was on Enhanced Barrier Precautions (EBP, a set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms [MDROs]). b. Ensure the Treatment Nurse (TN) who entered Resident 2's room and administered medication to Resident 2, wore a gown. Resident 2 was on EBP. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light was within reach for one of one sampled resident (Resident 194) in accordance to facility's policy titled Call Lights: Accessibility and Timely Response. This failure had the potential for Resident 194 not to receive care or receive delayed services to meet the residents' needs and could result in a fall or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident on hemodialysis (a treatment to cleanse the blood of wastes through a machine when the kidneys failed) an emergency kit (E-kit, contains the main items needed in an emergency) at bedside for one of two sampled residents (Resident 15). This failure had the potential for Resident 15 not to receive or received delayed care and treatment for complications caused by unexpected bleeding from the hemodialysis access site.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident rooms that measured at least 80 square feet per resident for 12 of 13 multiple resident bedrooms. Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14, did not meet the minimum square footage of 80 square feet per resident. This deficient practice had the potential to result in insufficient space to deliver care and services to the residents, affecting their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to locate one of one sampled resident (Resident 1), who eloped (the act of leaving a facility unsupervised and without prior authorization) from the dialysis center (a facility that provides treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney(s) have failed). This deficient practice had the potential to result in compromise to Resident 1's safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to readmit one of one sampled resident (Resident 1) as indicated in the facility's policy and procedure titled readmission to Facility. This failure resulted in Resident 1 to remain in General Acute Care Hospital 1 (GACH 1) for two days from 6/10/2024 to 6/11/2024.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment free from accident hazards for three of three sampled residents (Residents 7, 9 and 29) by failing to: a. Ensure the bed was at the lowest position for Residents 9 and 29 who were assessed as high risk for falls. b. Ensure the floor mattress (device used to reduce fall related trauma if a patient gets up from bed, loses balance, and falls to the floor) was placed close and not away from bed for Resident 7 who was assessed as high risk for fall. These deficient practices had the potential for accidents and severe injury secondary to falls for Residents 7, 9 and 29.

Inspectors wroteBased on interview and record review, the facility failed to document fluid intake every shift for one of one sampled resident on fluid restriction from 1/20/2024 to 2/10/2024 (Resident 19). This failure had the potential to result in adverse consequences for Resident 19.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Policy and Procedure (P&P) on Food Storage by failing to clearly label with open date, one opened mayonnaise container jar in one of one kitchen refrigerator and one opened bag with two pieces of chicken patties inside, in one of one kitchen freezer. These failures had the potential to result in food-borne illnesses (illness caused by ingesting contaminated food or beverages) to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to assist the resident at eye level during meal for one of one sampled resident (Resident 20). This failure had the potential to affect Resident 20's self-esteem, self-worth, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physician Orders for Life-Sustaining Treatment (POLST, a form designed to improve patient care by creating a portable medical order form that records patient's treatment wishes so that emergency personnel know what treatments the patient wants in the event of a medical emergency) and/or code status (describes the type of resuscitation procedures one would like the health care team to conduct if one's heart stopped breathing) were in the resident's medical record for one of one sampled resident (Resident 95). This failure had the potential to result in the delay of treatment to Resident 95 and provide care against the resident's will in the event of a medical emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 7) was free from physical restraint (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to his/her body). Resident 7's bed was against the wall on one side. This failure had the potential to result in accidents or decline in Resident 7's quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop and implement an individualized person-centered plan of care (details why a person is receiving care, assessed health or care needs, medical history, personal details, expected and aimed outcomes, and what care and support will be delivered, how, when and by whom) with measurable objectives, timeframe, and interventions to meet the residents' needs for one of one sampled resident (Resident 4) as indicated in the facility's Policy and Procedure, titled Comprehensive Care Plans. This deficient practice had the potential for Resident 4 not to receive the necessary care, treatment, and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the nasal cannula (NC) tubing (an oxygen delivery device) for one of two sampled residents (Resident 95). This failure had the potential to result in infection for Resident 95.

Inspectors wroteBased on interview, and record review, the facility failed to conduct annual competency for one of four sampled facility staff (Certified Nursing Assistant 2 (CNA 2). A CNA is a healthcare professional who provides basic care to patients under the supervision of a licensed nurse. This deficient practice had the potential for staff to not have the necessary skills to provide care to the residents.

Inspectors wroteBased on interview and record review, the facility failed to act upon the pharmacist's monthly Medication Regimen Review (MRR, a thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences and potential risks associated with medication)'s recommendations for one of five sampled residents (Resident 7). This failure had the potential to result in ineffective medication management that could result in adverse consequences (undesirable or non-therapeutic effect of the medication) to Resident 7.

Inspectors wroteBased on observation, interview, and record review, facility failed to follow the facility's policy and procedure titled Confidentiality of Personal and Medical Records by ensuring one of one sampled resident's identifiable, personal, and medical information were not exposed on the computer screen unattended and in view of unauthorized persons to view and access without the resident's consent or knowledge (Resident 4). This deficient practice resulted in violation of Resident 4's right to privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that oxygen simple mask (a basic disposable mask, made of clear plastic, to provide oxygen therapy) was kept in the storage bag when not in use for one of two sampled residents (Resident 1) in accordance with the facility's policy and procedure titled Oxygen Concentrator. This deficient practice had the potential to increase the risk of the spread of infection to the residents, staff, and other visitors in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident rooms that measured at least 80 square feet per resident for 12 of 13 multiple resident bedrooms. Rooms 1, 2, 3, 4, 6, 7, 8, 9, 10, 11, 12, and 14, did not meet the minimum square footage of 80 square feet per resident. This deficient practice had the potential to result in insufficient space to deliver care and services to the residents, affecting the quality of life of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to provide privacy to one of four sampled residents (Resident 3) while providing bed bath to Resident 3. This failure resulted in violation of Resident 3's right to privacy.