Victoria Haven Nursing Facility

Inspectors wroteBased on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on 4 of 92 days during the period of 7/1/25 through 9/30/25.

Inspectors wroteBased on employee record review and interview, the facility failed to complete performance reviews of Certified Nursing Assistants (CNAs) at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five out of five CNA (#1, #2, #3, #4, #5) employee records reviewed.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which focuses on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to show evidence of implementing a data driven QAPI plan for clinical measures, quality of life, and resident choices identified by the facility to improve the resident's quality of life.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed:1. During a respiratory illness outbreak, to implement Transmission-Based Precautions (TBP, an infection control measure to be used in addition to Standard Precautions for patients who may be infected) and to maintain infection surveillance;2. To implement and follow Enhanced Barrier Precautions for residents, including Resident #33;3. For Resident #12, to ensure sanitary practices were used by nursing while preparing and administering medications; and4. To ensure proper cleaning of resident shared equipment between resident use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services that met professional standards of practice for two Residents (#5 and #12), out of a total sample of 13 residents. Specifically, the facility failed to ensure medications were administered as ordered by the physician.

Inspectors wroteBased on interview and record review, the facility failed to provide wound care as ordered and as recommended to one Resident (#8), in a total sample of 13 residents. Specifically, the facility failed to:a. Carry over wound treatment orders for the bilateral lower extremities to the new electronic medication administration record to ensure treatment was provided for three weeks, andb. Follow the wound consultant recommendations to change the treatment to the lower extremity.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmacy recommendations from medication regimen reviews (MRR) were reviewed and addressed timely for two Residents (#2 and #27), out of a total sample of 13 residents.

Inspectors wroteBased on observations, records reviewed, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when two out of three nurses observed during a medication pass made three errors out of 28 opportunities, resulting in a medication error rate of 14.29%. Those errors impacted one Resident (#12), out of four residents observed.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed to ensure multidose vials of medications were labeled with a date opened and a use by date per manufacturer's guidelines in one of one medication carts and in one of one medication rooms.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and liquids were prepared and served in a form designed to meet the individual needs for three Residents (#34, #25, and #5), out of a total of 13 sampled residents. Specifically, the facility failed:1. For Residents #34, to follow the physician ordered therapeutic diet of minced moist (ground) and follow the downgrade from thin liquids to nectar thick liquids resulting on three occasions to be served the wrong diet consistency: a. Resident was served a whole hot dog while on a minced moist diet. b. Resident was served thin liquids at breakfast after the Resident's diet was downgraded the previous day to nectar thick liquids. c. Resident was served regular (thin) water resulting in Resident stating he/she choked.2. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure the main kitchen and 2nd floor kitchenette maintained sanitary conditions. Specifically, the facility failed to:1. Substitute pasteurized eggs (in-shell or liquid eggs gently heated between 130 degrees Fahrenheit (F) to 140 F to kill salmonella and bacteria without cooking them, making them safe for raw or undercooked recipes) for raw shell eggs when serving undercooked poached eggs to residents, placing them at risk for Salmonella Enteritidis (a virulent organism that may be present in raw shell eggs);2. Ensure open-refrigerated, ready-to-eat time/temperature controlled for safety, foods were labeled with the date of opening; and3. Ensure the second-floor kitchenette was regularly cleaned and did not contain expired foods.

Inspectors wroteBased on record review and interview, the facility failed to ensure staff notified the Physician in a timely manner recommendations for a medication change from the consulting Psychiatric (Psych) Nurse Practitioner (NP) for one Resident (#27), out of a sample of 13 residents. Specifically, the facility failed to notify the Physician of recommendations to increase Cymbalta (an antidepressant medication) from 60 milligrams (mg) to 90 mg. This delay resulted in Resident #27 not receiving an increased dose for 41 days.

Inspectors wroteBased on interviews and record review, the facility failed to ensure laboratory services were provided for one Resident (#2), out of a sample of 13 residents. Specifically, the facility failed to ensure a urinalysis with culture and sensitivity were obtained according to the physician's orders.

Inspectors wroteBased on interviews and records reviewed, the facility failed to timely notify the physician of an abnormal X-ray for one Resident (#1), out of 13 sampled residents. Specifically, the facility waited eight days to inform the physician of an X-ray result of osteomyelitis (an infection in the bone) to the right heel.

Inspectors wroteBased on interview and observation the facility failed to ensure one Resident (#2), out of 13 sampled residents, was referred to hospice services for an evaluation.

Inspectors wroteBased on record review and interview, the facility failed to provide education and/or offer the COVID-19 vaccination as required or appropriate per the Centers for Disease Control and Prevention (CDC) recommendations for one of one employee records reviewed for immunizations.

Inspectors wroteBased on record review and interview, the facility failed to maintain records of certified nurse aide (CNA) training for continuing competency that included no less than 12 hours of mandatory training per year for each CNA employed by the facility for one CNA (#1), out of five employee training records reviewed.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to ensure that infection control measures were implemented in order to prevent the potential development and spread of disease for two Residents (#1, #9), out of a total sample of 12 residents and three Residents during medication administration. Specifically, the facility failed: 1. For Resident #1, to ensure that transmission-based precautions (TBP) were implemented when the Resident was suspected to have a contagious respiratory illness; 2. For Resident #9, to ensure that TBP were implemented when the Resident refused COVID-19 testing during facility outbreak testing; and 3. To ensure staff donned gloves when touching the inside of the medication cup and/or its contents during medication administration.

Inspectors wroteBased on record review, document review, and interview, the facility failed to implement policies and procedures to ensure residents/residents' representatives were educated on benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the immunization, and offer and administer the influenza and pneumococcal immunizations in a timely manner for two Residents (#3, #10), out of five sampled residents. Specifically, the facility failed: 1. For Resident #3, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the influenza vaccine, offer the immunization, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccine and place in the Resident's medical record; 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations for five Residents (#1, #3, #10, #23, #327), out of a total sample of five residents reviewed for immunizations.

Inspectors wroteBased on interview and document review, the facility failed to ensure two Residents (#327, #2) were informed of and actively participated in his/her baseline plan of care within the first 48 hours following admission, out of a total sample of 12 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of practice. Specifically, the facility failed to ensure a treatment order was in place for a dressing to Resident #327's left lower extremity.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#10), in a total sample of 12 residents. Specifically, the facility failed to ensure nail care was performed for Resident #10.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the monthly Medication Regimen Review (MRR) reports for two Residents (#9, #23), out of a total sample of 12 residents, were included in the medical record and acted upon in a timely manner. Specifically, the facility failed: 1. For Resident #9, to ensure the monthly MRR reports were included in the medical record or readily available for review to indicate the Physician's response to the recommendations made by the Consultant Pharmacist; and 2. For Resident #23, to act promptly upon recommendations made by the Consultant Pharmacist during the monthly MRR for consideration of a gradual dose reduction (GDR) of Clozapine (an antipsychotic medication).

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident's (#23) drug regimen was free from unnecessary psychotropic medications, out of a total sample of 12 residents. Specifically, the facility failed to ensure a gradual dose reduction (GDR) of the antipsychotic medication Clozapine was attempted, unless clinically contraindicated and documented in the medical record, in an effort to discontinue the drug.

Inspectors wroteBased on observation and interviews, the facility failed to ensure that all drugs were labeled in accordance with currently accepted professional principles. Specifically, medications were stored, unlabeled, in a small box in the top right-hand side of the top drawer of the facility's only medication cart.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days after a resident assessment was completed for three Residents (#5, #19, and #328), out of a total sample of 12 residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change in the resident's physical, mental, or psychosocial status for one Resident (#11), out of a total sample of 12 residents. Specifically, the facility failed to notify the physician of the inability to obtain a urine sample for Resident #11's urinalysis culture and sensitivity (UA C&S) on two occasions: (1) 9/5/23 through 9/18/23 (14 days before the provider was notified and the order was discontinued) and (2) 10/27/23 through 12/8/23 (42 days before the resident was sent to the hospital), resulting in the progression of symptoms and the Resident being hospitalized for five days with pyelonephritis (kidney infection) and nephrolithiasis (kidney stone), requiring a peripherally inserted midline catheter for intravenous (IV) antibiotics.

Inspectors wroteBased on record review, policy review, and staff interview, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to identify and address a change in condition and provide necessary care and treatment for one Resident (#11), out of a total sample of 12 residents. Specifically, the facility failed to monitor, identify, and notify the physician of a change in condition resulting in Resident #11 being hospitalized for five days with pyelonephritis (kidney infection) and nephrolithiasis (kidney stone), requiring a peripherally inserted midline catheter for intravenous (IV) antibiotics.

Inspectors wroteBased on observations, record review, and interview, the facility failed to provide care in accordance with professional standards of practice for three Residents (#1, #3, and #14), out of a total sample of 12 residents. Specifically, the facility failed: 1. For Resident #1, to schedule a cardiology appointment as ordered after hospitalization for heart failure; 2. For Resident #3, to obtain a speech therapy evaluation as ordered; and 3. For Resident #14, to follow physician's orders for the daily use of a splint to the right arm with geri sleeve (stocking sleeves that protect from friction and shearing).

Inspectors wroteBased on observation, interview, and facility policy, the facility failed to ensure that drugs and biologicals used in the facility were labeled and stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, 1. The facility failed to ensure that medications stored in the medication storage room, including but not limited to, single-use parenteral medications, were labeled with the appropriate information including the resident's name, dose, route, time and frequency of administrations, when dispensed by the pharmacy; and 2. The facility failed to ensure staff properly labeled all medications stored in one of one medication cart reviewed.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to implement policies and procedures to ensure residents/residents' representatives were educated on benefits and potential side effects of immunizations, ensure the medical record contained documented consent or refusal of the immunization, and offer and administer the influenza and pneumococcal immunizations in a timely manner for 5 out of 5 Residents sampled (#1, #3, #8, #11, and #14). Specifically, the facility failed: 1. For Resident #1, to educate the Resident and/or the Resident's representative on the benefits and potential side effects of the pneumococcal vaccine, offer the immunization, and document on the Informed Consent the Resident's consent to receive or refusal of the vaccine and place in the Resident's medical record; 2. [...]

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide education, assess for eligibility, and offer COVID-19 vaccinations per the Centers for Disease Control and Prevention (CDC) recommendations and facility policy for five residents (#1, #3, #8, #11, and #14), out of a total sample of five residents reviewed for immunizations.

Inspectors wroteBased on observation, interview, policy review, and record review, the facility failed for two Residents (#2 and #11) to develop and implement comprehensive care plans to reflect the individual needs of the Residents, out of a total sample of 12 residents. Specifically, the facility failed: 1. For Resident #2, to develop and implement a genitourinary system care plan related to urinary incontinence, benign prostatic hyperplasia (BPH) with lower urinary tract symptoms, chronic kidney disease stage three (CKD-Stage 3), and hyperkalemia (high potassium); and 2. For Resident #11, to develop and implement a genitourinary system care plan related to chronic urinary tract infections (UTIs), history of extended spectrum beta lactamase (ESBL) resistance, chronic obstructive pyelonephritis (kidney infection), and calculus of the kidney (kidney stone).

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater when one of one nurse made two errors in 29 opportunities, totaling a medication error rate of 6.9%. These errors impacted two Residents (#11 and #6), out of seven residents observed.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to develop a policy to ensure safe and sanitary storage, handling, and reheating of food brought to the facility for residents from family and visitors.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed for one Resident (#11), out of a total sample of 12 residents, to maintain an accurate medical record in accordance with accepted professional standards and practices. Specifically, the facility failed to ensure Resident #11's refusal to wear a splint and sling to their right arm was documented accurately.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents and/or their Representatives were provided with transfer/discharge notices prior to a hospital transfer for three Residents (#7, #1, and #11), out of a total sample of 12 residents.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide written notification of the bed hold policy to the Resident and/or Resident Representative prior to discharge to a hospital transfer for three Residents (#7, #1, and #11), out of total sample of 12 residents.