Victoria Nursing & Rehabilitation Center, Inc.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure positioning devices were in place as prescribed for two (Resident #184 and Resident # 240).out of thirty-six sampled residents as evidenced by Residents #184 and Resident # 240 were found in bed without their ordered heel protectors. The facility had 311 residents at the time of the survey.

Inspectors wroteBased on observations, records reviewed and interviews, it was determined that the facility did not maintain adequate supervision to ensure a safe environment that is free from accident and hazards as evidenced by one (Resident #48) out of five residents who smoked was observed removing a lighter that he kept in his pocket. There were 311 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, interview and record review the facility failed to administer oxygen therapy as ordered for two out of twenty-six residents receiving oxygen (Resident #23 and Resident # 329). As evidenced by Resident # 23's oxygen concentrator was observed at 2.5 Liters Per Minute (LPM) instead of 3 LPM and Resident # 329's oxygen concentrator was being delivered at 1.5 LPM instead of 2 LPM.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide safe and secure storage of biologicals for five (Resident #31, Resident #184, Resident #202, Resident #224 and Resident #240) out of thirty-six sampled residents. There were 311 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct identified quality deficiencies in the problem area related to repeated deficient practice for F695- Respiratory/Tracheostomy care and Suctioning, F761- Label/Store Drugs & Biologicals. There were 311 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation, record review and interview, the facility failed to implement a fall care plan for one (Resident #7) out of one sampled resident at risk for falls as evidenced by Resident # 7 was left unattended/unsupervised lying in a high positioned bed. This deficient practice increases the resident's risk of falling and potentially sustaining severe life-threatening injuries.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide an environment that is free from potential accidents and hazards for one (Resident #7) out of three sampled residents, as evidenced by Resident # 7 who is at risk for falls was observed in high positioned bed unattended/unsupervised. This deficient practice increases the resident's risk of falling and potentially sustaining severe life-threatening injuries. There were 51 residents residing on the third floor at the time of survey. The ndings included:Observational tour of the facility's third floor on 8/4/25 at 8:43 AM, revealed Resident #7 lying in a high positioned bed, one oor mat was on the left side of the bed and no staff was present in the room. The surveyor immediately noti ed Staff A, Certi ed Nursing Assistant, who was gathering linens from the cart on the opposite side of the hallway. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide privacy on one out of eight medication cart computer screens and failed to provide privacy during medication administration as evidence by resident's information visible on the unattended open sixth floor's west cart computer screen and staff failed to provide privacy during medication administration for Resident #57.

Inspectors wroteBased on record review and interview the facility failed to ensure an accurate Level I Preadmission Screening and Resident Review (PASRR) was completed in a timely manner for two residents (Resident #254 and Resident #266) out of 12 residents sampled as evidenced by a Level I PASRR dated 7/24/24 for Resident #254 omitted diagnosis of Generalized Anxiety Disorder and Level I PASRR dated 10/9/24 for Resident#266 omitted diagnosis of Major Depressive Disorder. There were 307 residents residing in the facility at the time of survey.

Inspectors wroteBased on observation, interview and record review the facility failed to administer oxygen as ordered for one Resident (#244) out of twelve sampled residents as evidenced by Resident #244 was observed without nasal cannula in place resulting in decreased oxygen saturation level.

Inspectors wroteBased on observations, interviews and record review the facility failed to properly store medication for four residents (Resident #254, Resident #6, Resident #21, and Resident #163) out of eight sampled residents; as evidenced by observations of a nasal spray at the bedside of Resident#254, sore throat medicine at Resident#6's bedside, Ammonium lactate and Ketoconazole shampoo on Resident#21' nightstand, eye drop and nasal spray at Resident#163's bedside There were 307 residents residing in the facility at the time of survey.

Inspectors wroteBased on record review and interview, the facility failed to accurately code a minimum data set (MDS) for one (Resident #299) out of one resident reviewed for MDS accuracy as evidenced by staff incorrectly coding the resident's discharge status to an acute level of care.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure pharmaceutical procedures were followed during medication administration for two (2) (Resident #233 and #92) out of seven (7) residents observed for medication administration with 35 opportunities and one (1) medication cart electronic screen was not locked on the 5th floor medication cart #2. There were 303 residents residing in the facility at the time of this survey. The Findings Included: 0n 07/18/23 at 8:40 AM during the medication administration observation with Registered Nurse (Staff B). Staff B did not have on the medication cart and was unable to administer one prescribed medication (Apixaban Oral Tablet 5 Milligram (mg) 1 tablet) for Resident # 233. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the medication error rate was below five percent, as evidenced by an error rate of 5.71% percent during the medication administration observation. Two (2) medication errors were identified while observing a total of 35 opportunities, affecting Resident # 233 and #92. The Findings Included: 1. 0n 07/18/23 at 8:40 AM during the medication administration observation with Registered Nurse (Staff B). Staff B did not have on the medication cart and was unable to administer one prescribed medication (Apixaban Oral Tablet 5 Milligram (mg) 1 tablet) for Resident # 233. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to demonstrate effective plan of actions were implemented to correct identified quality deficiencies in the problem area related to repeated deficient practices cited during this survey for F755 Pharmacy Services/Procedures/Pharmacist/Records as evidenced by the facility failed to follow Pharmacy procedures for ordering and administering medications for Resident #233 and medications cart security. This deficient practice has the potential to increase the risk of negative resident outcomes and to affect the 303 residents currently residing in the facility at the time of the survey.