Victoria Crossing Rehabilitation Center

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure two (#25 and #19) of two residents reviewed for self administration of medications were assessed by the facility and a physician order was obtained to allow for the self-administration of medications related to the administration of oral and nebulized medications.

Inspectors wroteBased on observation and interview, the facility failed to provide Meal Menus to four (Resident #24, Resident #67, Resident #105 and Resident #110) out of four residents reviewed for choices. Findings Included: During an interview on 01/05/2026 at 9:27 a.m., Resident #24 stated they have not passed out menus in a while, so she has no idea what she is getting to eat until they bring the trays in. An observation of Resident #24's wall and overside table revealed no meal menu. During an interview on 01/05/2025 at 10:02 a.m., Resident #67 stated they don't pass out menus anymore, so I never know what they are bringing me to eat. They will bring my tray, and I can order something else, but I cannot order it ahead of time since I don't know what they are serving. An observation of Resident #67's room revealed no meal menu was posted. [...]

Inspectors wroteBased on record review and interview, the facility failed to allow the resident to remain in the facility during a pending appeal for one resident (#133) out of four residents reviewed for discharge. Findings Included:Review of Resident #133's admission record revealed an admission date of 10/01/2025 and a discharge date of 11/04/2025. Resident #133 was admitted to the facility with diagnosis to include orthopedic aftercare following surgical amputation, other acute osteomyelitis, left ankle and foot, chronic obstructive pulmonary disease, and muscle weakness. Review of a care plan for Resident #133 initiated on 10/03/2025 revealed a focus; [Resident #133] wishes to return home with her [family member]. The goal showed the resident will be able to verbalize/communicate required assistance post-discharge and the services required to meet needs before discharge. [...]

Inspectors wroteBased on record review and interview, the facility failed to document the required discharge/transfer notifications and the reason for discharge for one resident (#133) out of four residents reviewed for discharge. Findings Included:Review of Resident #133's admission record revealed an admission date of 10/01/2025 and a discharge date of 11/04/2025. Resident #133 was admitted to the facility with diagnosis to include orthopedic aftercare following surgical amputation, other acute osteomyelitis, left ankle and foot, chronic obstructive pulmonary disease, and muscle weakness. Review of Resident #133's electronic medical record revealed revealed no documentation regarding required elements for discharge per policy. An interview was conducted on 01/08/2026 at 3:56 p.m. with the Social Services Director (SSD). The SSD stated having worked at this facility for only a week. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure Preadmission Screening and Resident Review (PASRR)s for two (#3 and #105) were updated to include current diagnoses and screening questions were answered appropriately of two residents sampled for PASRR.Findings Included: During an interview on 01/05/2025 at 10:46 a.m., Resident #3 stated the people who speak spanish have it out for me. They are talking about me in Spanish. When I first got here, they (spanish speaking people) accused me of molesting my daughter. Resident #3 was not able to identify any certain person and just referred to the spanish speaking people. [...]

Inspectors wroteBased on interviews, observation, and record review, the facility failed to provide Activities of Daily Living (ADLs) related to fingernail trimming for one resident (#135) out of four residents sampled. Findings Included: During an observation and interview on 01/05/2026 at 10:30 a.m., Resident #135 was observed to have long untrimmed nails with black build-up underneath. Resident #135 stated I would like my nails trimmed. I don't like them being this long. During an interview and observation on 01/07/2026 at 9:04 a.m., Resident #135's was observed to have long untrimmed nails with black build up underneath. Resident #135 stated, I have asked them to trim my nails, but they have not done it yet. Review of Resident #135's admission record revealed an admission date of 01/02/2026. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to follow physician orders related to medication perimeters and wound care for two residents (#10 and #22) out of two residents sampled. Findings Included: Review of Resident #10's admission record revealed an admission date of 11/18/2025. Resident #10 was admitted to the facility with diagnosis to include hepatic failure, acute embolism and thrombosis of right femoral vein, portal hypertension, hypotension, and idiopathic hypotension, sedative, hypnotic or anxiolytic abuse. Review of Resident #10's physician orders dates active as of 01/08/2026 revealed:Midodrine Give 15 mg by mouth three times a day for Hypotension Hold if Systolic Blood Pressure (SBP) great than 130. Start Date: [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to provide toileting needs for one (#97) of two residents sampled for bladder and bowel incontinence.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status for three (#1, #71, and #113) residents of eight residents reviewed for nutrition.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure that the medication error rate was less than 5.00%. Twenty-five medication administration opportunities were observed and three errors were identified for two (#138 and #7) of five residents observed. These errors constituted a 12.00% medication error rate.

Inspectors wroteBased on observations, record review, and interviews, the facility did not follow professional standards for food service safety in the kitchen as evidenced by: a) food stored in the walk-in fridge and freezer were not labeled or stored properly b) garbage in the kitchen prep area was not contained safely or hygienically; c) food stored in the nourishment rooms were not labeled or stored properly; d) hand hygiene was not performed during a change of tasks. Findings Included:On 1/5/26 at at 9:11a.m., an initial tour of the kitchen was conducted with the Dietary Director (DD). On 1/5/26 at 9:20a.m., an observation of the facility's walk-in refrigerator revealed an opened, and unlabeled gallon of milk. The DD confirmed that the milk was not properly labled and stored. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure proper infection control practices were in place on one out of four units related to proper personal protective equipment (PPE) use, timeliness of contact precaution orders, and hang hygiene.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's family/responsible party and the resident's physician of a change in condition for two (#1, #12) of 12 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide wound assessments and wound care for 1 (Resident #12) of 1 sampled residents for wounds.

Inspectors wroteBased on interviews and record review, the facility failed to ensure Hemodialysis (HD) care was provided per physician orders for one (#1) of two dialysis residents reviewed.