Victoria Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the observance of proper sanitation and food handling practices when dietary aid (DA 1) failed to use a beard net during food handling. This failure had the potential to result in foodborne illnesses among the residents. During an observation, on 6/22/26, at 9 a.m., in the kitchen, a dietary aid (DA 1), was observed sporting a goatee (a style of facial hair defined by a small, pointed, or tufted beard grown entirely on the chin). The goatee measured approximately 1 to 2 inches in length. Additionally, DA 1 had noticeable stubble on both cheeks and upper lip. DA 1 was not wearing a beard net. When asked why he was not wearing a beard net, DA 1 stated, I forgot. This exchange was witnessed by the registered dietician (RD). The RD acknowledged the observation and deficient practice. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the plan of care (POC) for respiratory (breathing) condition and a wound infection isolation protocols were accurately reflected for two (2) of 35 sampled residents (Resident 1 & 146) when:Resident 1 use of suction machine to remove excess oral secretions (fluids). Resident 146 was placed both for contact isolation precautions and enhanced barrier precautions. This failure had the potential to hinder continuity of care, insufficient management of residents' needs and not to address all aspects of residents' condition including the infection control protocols without the updated and accurate information of the care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an extended-release medication (medication formulated to release its active ingredients slowly into the bloodstream over a prolonged period) was administered accurately in accordance with written orders of the attending physician for one of 35 sampled residents (Resident 127). This failure had the potential to alter the absorption of the medication and can increase the risk of side effects and overdose. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored when rectal and oral medications were observed stored next to each other in one medication cart. This failure had the potential to result in medication administration errors leading to adverse drug reactions, reduced effectiveness of treatment, and a decline in the resident's physical or mental well-being. During a review of the facility's policy and procedure (P&P) titled Storage of Medications, undated, the P&P indicated Orally administered medications are kept separate from externally used medications such as suppositories, liquids and lotions. During a concurrent observation and interview on 6/24/26 at 3:52 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its infection prevention and control practices when:Staff was observed handling soiled linen for one of 35 sampled residents (Resident 146), resulting in contaminated linen being improperly placed and managed, posing a risk of transmission of infectious agents. Soiled linen was observed left in the bathroom occupied by two unsampled residents (Resident 2 and Resident 3). 2. During a review of the facility's P&P titled, Soiled Linen, dated 5/2026, the P&P indicated, It is the policy of this facility to handle, collect, transport, process, and store soiled linen in a manner that minimizes the transmission of microorganisms, protects residents and healthcare personnel from exposure to infectious materials, and compiles the current CDC Standard Precautions and applicable federal, state, and local regulations. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure routine inspections and maintenance of electrical equipment in the facility to ensure safe operating condition and the welfare of residents and staff. This failure resulted in a burnt electrical wall socket in the kitchen and had the potential to result in a fire in the facility. During an observation, on 6/22/26, at 9 a.m., in the kitchen, a burnt electrical wall socket was noted. The electrical wall socket is a multi-plug with 4 plug sockets which can accommodate 4 different appliances plugged simultaneously. The electrical wall socket is a 3-pronged plug socket (standard electrical connector that attaches a device to a power source. The third pin is called the ground pin. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment when a water leak was observed underneath the sink in one medication storage room. This failure had the potential for mold growth and unsanitary and unsafe conditions for the staff. During a review of the facility's policy and procedure (P&P) titled Environmental Conditions Environmental Rounds, dated 1/2026, the P&P indicated It is the policy of this facility that the facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public through monthly environmental rounds. During a concurrent observation and interview on 6/24/26 at 2:46 p.m., with the Minimum Data Set Coordinator (MDSC) 2, the [NAME] medication room was inspected. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) was administered Cipro (antibiotic used to treat infections) within a reasonable amount of time after a new order. This facility failure had the potential to result in the progression of the infection to a severe infection or sepsis (a life-threatening infection).

Inspectors wroteBased on interview and record review, the facility failed to follow physician's orders for Lovenox (Enoxaparin Sodium Injection- an anticoagulant/blood thinner), for one of two sampled residents (Resident 1). This facility failure had the potential to result in life-threatening condition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure: 1. Care plan interventions were implemented for three of 38 sampled resident's (Residents 61, 123 and 138). 2. Medication administration and interventions were completed as identified in the care plan for one of 38 sampled residents (Resident 682). 3. Consistent turning and repositioning of one of 38 sampled residents (Resident 5). 4. A snack was provided during Dialysis (treatment that removes waste and excess fluid from the body) days for one of 38 sampled residents (Resident 36). 5. Pillows were placed to offload pressure from heels for one of 38 sampled residents (Resident 121). This failure had the potential to result in the needs of residents not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure it promoted and maintained dignity and respect for three of four sampled residents (Residents 110, 240 , and 66) when: 1. Resident 110, confidential medical information was publicly displayed. This failure resulted in a violation of their right to dignity. 2. Resident 240, call light was not answered timely. This failure resulted in feeling embarrassed, frustrated, and angry. 3. Resident 66, call light was not answered timely. This failure resulted in feeling angry, frustrated, in pain, hungry, thirsty, and embarrassed.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents (Resident 69), had the most current Physician Orders for Life-Sustaining Treatment (POLST) a form designed to improve resident care by creating a portable medical order form that records residents' treatment wishes so that emergency personnel know what treatments the resident wants in the event of a medical emergency. This failure had the potential to result in Resident 69's end of life wishes not to be honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident (Resident 106), was involved in review and revision of their care plan during the interdisciplinary (IDT) meeting of health professionals who plan and coordinate resident care meeting. This failure resulted in Resident 106 not being given the right to participate in deciding treatment options.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records in accordance with professional standards and practices for two of four sampled residents (Residents 93 and 13) when: 1. The facility did not maintain a complete, accurately documented, readily accessible, and systematically organized room transfer form for Resident 93's relocation. 2. The facility failed to monitor Resident 13's depression and mood as ordered by the physician. These failures had the potential to impact resident rights, care planning, and the provision of appropriate care due to inaccurate or incomplete documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to Infection Prevention and Control Program (IPCP) when: 1. Staff failed to follow Enhanced Barrier Precautions (EBP) when providing care for one sampled resident (Resident 682). 2. Staff failed to follow infection control protocols while assisting two unsampled residents (Residents 12 and Resident 94) with feedings. 3. Staff failed to label oxygen tubing, nebulizer mask, and nebulizer tubing for two sampled residents (Residents 232 and 93) and did not change contaminated gloves for one unsampled resident (Resident 240), which did not align with infection control protocols. 4. Staff failed to perform handwashing during wound care for one sampled resident (Resident 434). These failures had the potential to result in the spread of organisms from staff members to other vulnerable residents.

Inspectors wroteBased on observation and interview, the facility failed to ensure to provide a functional and comfortable environment for residents when pull cords for overhead night lights were missing. This failure resulted in denying residents the use of a night light and had the potential to result in adverse consequences during nighttime hours, including increased fall risk.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident representative was notified promptly of a resident's fall for one of two sampled residents (Resident 1). This failure resulted in Resident 1's representative having delayed involvement in decision making regarding Resident 1's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the physician responded promptly to notification of a resident's fall for one of two sampled residents (Resident 1). This failure resulted in Resident 1's delayed transfer to the emergency room (ER) after a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), had their antibiotic (medication used to treat an infection) administered without interruption following a transfer from an acute care facility (hospital) to the skilled nursing facility (nursing home). This failure had the potential to result in Resident 1's antibiotic treatment being less effective and/or prolonging treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1), was provided antibiotic (medication used to treat an infection) on discharge from the facility. This failure resulted in concern for Resident 1's Representative (RR) at the time of discharge.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Residents 1 and 2), had interventions (actions to be taken) on their care plans (an outline of the care the facility will provide to the resident) related to pressure ulcers(bedsores) to include: a) Ensuring heels of the feet were offloaded (the practice of reducing pressure) from the bed for Residents 1 and 2. b) Identifying a frequency for turning and repositioning (helping move or reposition to relieve pressure) for Residents 1 and 2. c) Identified an amount of fluid intake for Resident 2. These failures resulted in worsening of a pressure ulcer (Resident 2), had the potential to result in worsening of pressure ulcers (Resident 1) and fluid overload (too much water [Resident 1]).

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2) had an accurately documented skin assessment. This failure resulted in Resident 2 having an inaccurate resident care history.

Inspectors wroteBased on interview and record review, the facility failed to report to the California Department of Public Health (CDPH) allegation of abuse timely for one of two sampled residents (Resident 1). This failure had the potential to delay investigation and affect physical and psychosocial well-being of the resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) had a comprehensive care plan developed and implemented for a resident to include specific food preference of a Kosher (a term applied to any food that complies with dietary rules in Judaism [religion]) diet. This failure resulted in Resident 1 receiving foods that are not considered Kosher and the potential for Resident 1's nutritional needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) had their rights protected when a Certified Nursing Assistant (CNA) was rude to them. This failure resulted in Resident 1 becoming agitated and wanting to leave the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 2), had their significant family invited to participate in the development of their care plan. This failure resulted in Resident 2 and their spouse (Family) not knowing what to expect for discharge.

Inspectors wroteBased on record review, interviews, facility policy review, and document review, the facility failed to ensure a Minimum Data Set (MDS) accurately reflected the use of an antipsychotic medication for 1 (Resident #48) of 5 sampled residents reviewed for unnecessary medications.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide nail care to 1 (Resident #122) of 2 sampled residents reviewed for assistance with activities of daily living (ADLs).