Victoria Post Acute Care

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served to residents was plated with an appetizing presentation. This failure had the potential to lead to a negative dining experience, resulting in reduced appetite, weight loss and feelings of disappointment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the interdisciplinary team (IDT - a group of healthcare professionals collaborating residents nursing home care, services, and plan) completed documentation in the medical record to indicate it was clinically appropriate for the resident to self-administer medications for one of 10 sampled medication pass observation residents (Resident 89). This failure had the potential for the resident to experience preventable medication errors, preventable infections from accidental cross-contamination of microbes (germs), and inappropriate self-administration of drugs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of eight residents (79 and 138), who were unable to carry out activities of daily living (ADL-self-care activities such as grooming, bathing, and toileting), received assistance with nail care (cleaning, trimming and/or filing of nails). This deficient practice had the potential for Resident 79 and Resident 138 for injury and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective pharmaceutical services when:1. In one of two medication rooms refrigerators (North Medication Room), one opened and undated multiple-dose Aplisol (tuberculin purified protein derivative - aid to diagnose the tuberculosis infection) vial was observed stored in the medication refrigerator and available for use. This failure had the potential for the resident(s) to be exposed to ineffective Aplisol due to possible oxidation (chemical process) and degradation (reduced quality) which may affect potency (effectiveness) if the opened and undated vials were not discarded according to the drug manufacturer's instructions. 2. In one of one medication carts (Southwest Medication Cart), one discontinued medication for Resident 76 was not removed from the medication cart and available for use. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and effective medication labeling when: 1. Two of two opened inhaler mouthpieces were not dated in accordance with the drug manufacturer's specifications (requirements). This failure had the potential to expose the residents to ineffective medications. 2. Three of three opened inhaler mouthpieces were not properly labeled with sufficient information to clearly identify the specific resident. This failure had to potential to cause medication errors and preventable infections from cross-contamination from other residents if accidently mixed up with other residents' similar or same drugs.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate infection prevention and control practices when expired food was left in a dedicated refrigerator for the residents. This failure had the potential to result in foodborne illness to an already vulnerable population.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure to a complete medication order for one of 10 sampled medication pass observation residents (Resident 115). This failure had the potential for the resident to experience preventable medication errors and adverse clinical outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards of practice for two of eight residents reviewed for infection control when: 1. Resident 104's nebulizer (a treatment with liquid medication delivered as a fine mist inhaled into the lungs through a mouthpiece or mask) mask was placed on top of the bedside table uncovered, 2. Resident 137's nasal mask for continuous positive airway pressure (CPAP- a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) was on the floor. This deficient practice had the potential to expose residents to bacteria which could lead to infections.

Inspectors wroteBased on interview and record review, the facility failed to check a resident's blood sugar for a resident with diabetes (high blood sugar) for one of two sampled residents reviewed for diabetes management (Resident 1). This failure had the potential to place Resident 1 at risk for poor diabetes management.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and orderly discharge and continuum of care, for one of three residents (Resident 1), when Resident 1 was discharged to a homeless shelter that was closed and not accepting any admissions for the evening, when reviewed for discharges. This failure resulted in Resident 1 not having a place to sleep or have supervision for the evening of his discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained for food storage according to standards of practice when: 1. One ice machine, and two three-compartment sinks did not have a proper air gap system to adequately prevent backflow of contaminated foods. 2. One facility prep sink was covered with white stained deposits, rust, and discolored raised pebble sized rock-like substance permanently embedded on the surface was being used. 3. The facility mixer for preparing food did not have a splash guard to prevent contaminating floor and kitchen equipment surfaces during use. 4. The facility did not safely prepare a meat recipe by using unpasteurized eggs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food served was in a palatable, flavorful manner that maintained the nutritional value of the menu items served when: 1. Food complaints were not being addressed appropriately. 2. The recipe was not followed during the preparation for a meat recipe. Cross-reference (F812) This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 110.

Inspectors wroteBased on observations, interviews, record reviews the facility failed to provide a safe, sanitary (clean), and comfortable environment to help prevent highly contagious infections when: 1. Facility did not store respiratory equipment properly for Resident 261. 2. Licensed Nurses (LN) did not have interventions in place to clean Resident 33's continuous positive airway pressure (CPAP) mask according to professional standards of practice. 3. Three certified nursing assistants (CNA) did not practice infection control protocols with hand hygiene and/or the use of protective personal equipment (PPE: clothing or equipment that protects people from injury or infection in the workplace) for residents (Resident 45, Resident 95, and Resident 108) on transmission-based precautions. a) Resident 45 with droplet precautions for corona virus (COVID-19: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat two of seven residents reviewed for resident rights, in a dignified manner when staff stood over while feeding the residents (Resident 63 and Resident 67). In addition a resident (Resident 65) was served food in a Styrofoam (foam-like) food container. This deficient practice had the potential for residents' self-esteem and self-worth to be devalued and as a result Resident 65 had a difficult time with self feeding requiring feeding assistance from the nursing staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environments for five of 22 sampled residents (Resident 33, Resident 80, Resident 9, Resident 14 and Resident 54) when: 1. Resident 33's sliding door was stuck in a position that was unable to open and close fully causing safety concerns along with a damaged closet door and an ineffective overhead bed lighting to cause safety and emotional distress for Resident 33. 2. Resident 80's telephone wall jack was detached and hanging from the wall causing the telephone line to dangle with concerns for pests and safety concerns to cause accidents. 3. Resident 9, Resident 14 and Resident 54's rooms were not comfortable. These failures have caused and/or had the potential to place residents, staff, and visitors at risk for harm due to safety concerns and emotional distress.

Inspectors wroteBased on interviews, and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission for one of three residents (Resident 94) reviewed for dialysis. This deficient practice had the potential to delay the care planning process that would have been identified by Resident 94's care area assessments (CAA) to meet Resident 94's individualized care needs.

Inspectors wroteBased on interviews, and record review, the facility failed to accurately code the Minimum Data Set (MDS: a nursing assessment tool) for one of two residents (Resident 45) reviewed for dementia care. As a result, the facility sent Resident 45's MDS to the federal database with inaccurate picture of the Resident 45's current health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of seven residents reviewed for activities of daily living (ADL- self- care activities such as grooming, bathing, and toileting), who were unable to carry out their ADLs, received assistance with nail care (cleaning, trimming and/or filing of nails) and grooming. (Resident 7, 63 and 67) This deficient practice had the potential for the residents' personal well-being to be affected.

Inspectors wroteBased on observations, interviews, and record review, the facility left medications unattended at the bedside for one of eight residents (Resident 80) reviewed for medication storage. These failures had the potential for medication misuse, divergence (another person taking medications or medications used wrongfully), and/or severe allergic complications.

Inspectors wroteBased on interview and record review the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement plan (QAPI-plan developed by QAA to help improve conditions in the facility), trends identified by surveyors during the recertification survey concerning grooming/hygiene and the cleaning of bi-level positive airway pressure/continuous positive airway pressure machines (BIPAP/CPAP- a type of noninvasive ventilation that helps you breathe). This failure had the potential for the facility to overlook trends in resident care that might have affected residents' dignity and/or health. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 of 2 residents (Resident 1) reviewed for 1:1 feeding assistance (staff member present to watch/help resident to eat during meals), was supervised during a meal. This failure placed Resident 1 at risk for aspiration (inhaling food particles into the lungs), choking, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (1) when Resident 1 reported being treated roughly by a staff member/licensed nurse (LN) 1. As a result, LN 1 was not immediately removed from providing care to the resident, per the facility ' s abuse policy and procedure. This failure had the potential to affect Resident 1 ' s feeling of safety and protection while at the facility. (Cross-reference F609)

Inspectors wroteBased on interview and record review, the facility failed to report an alleged abuse complaint to the State Agency (SA), protective services, and/or law enforcement entities per facility policy. As a result, a resident ' s (1) allegation of being mishandled was not completely investigated, which had the potential to affect Resident 1 ' s safety, comfort, and well-being. (Cross-reference F600)

Inspectors wroteBased on interviews and record review, the facility failed to ensure a safe and appropriate discharge for one of three sampled residents (Resident 1). As a result, Resident 1 was inappropriately discharged to an independent living facility (ILF; a residence for individuals who have the mental capacity to live independently without medical or physical assistance with their daily living tasks) that placed Resident 1 at risk for harm and/or injury.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an ongoing infection surveillance monitoring for 3 of 5 sampled residents (Resident 8, 9, and 11) when: 1. Resident 8's infection surveillance (infection care area and screening tool) assessment did not include Resident 8's symptoms of dysuria (painful or uncomfortable urination) as a urinary tract infection (UTI) symtpom, for on-going surveillance. 2. Resident 9's infection surveillance assessment did not include Resident 9's burning to vaginal area related to the use of a urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag), for on-going surveillance. 3. Resident 11 was diagnosed with corona virus 19 (COVID-19; [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and administer pneumococcal vaccine (PV, immunization against bacteria that causes pneumonia [lung infection]) for two of five sampled residents (2 and 5). This failure had the potential to cause health complications for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately follow up on one of 21 residents (Resident 39) who, had a reported abnormally low blood pressure (When the pressure of circulation blood against the walls of blood vessels read below 90/60 mmHg). As a result, Resident 39 developed an acute change in condition (sudden clinically important deviation from a resident's baseline to prevent complications) which resulted in unresponsiveness and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure comprehensive resident-centered care plans were developed for four of 21 sampled residents (92, 90, 7, and 155). 1. A care plan was not developed for Resident 92's PICC line. A PICC line is a peripherally inserted central catheter that provides access to the large vein carrying blood to the heart to administer medication for long-term use. 2. A care plan was not developed for an Antipsychotic medication for Resident 90. Antipsychotic medications control psychotic symptoms such as delusions, hallucinations, and unstable moods. 3. A care plan was not developed for Resident 90's actual falls, which occurred on two occasions. 4. A care plan did not include a physician's order for a specific fall intervention for Resident 7 (cross reference F689 #2). 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's QAPI/QAA (Quality Assurance and Performance Improvement/ Quality Assessment and Assurance) Committee failed to ensure action plans for a complaint investigation (exit date 6/10/22) related to change of resident condition and notification of change of condition were fully implemented as their plan of correction (POC) indicated. The following deficient areas as it related to resident change of condition were identified: -Notify of Changes (cross reference F-Tag 580) -Accidents and Hazards (cross reference F-tag 689 # 1) As a result, the facility remained noncompliant with the deficiency cited during the prior complaint survey, which had the potential to affect the health and safety of residents.

Inspectors wroteBased on record review, the facility failed to ensure one of 21 sampled residents (28) had a completed end of life wishes or a POLST (physician orders for life sustaining treatment) in their record. As a result, there was a potential for residents to not have their end of life wishes honored.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the MDS (Minimum Data Set- an assessment tool) was accurate for one of 21 sampled residents (48) related to weight loss. This failure had the potential to affect the care provided to Resident 48.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 21 residents (51 and 48) had timely and appropriate care plan review and revision, when: 1. Resident 51's written fall care plan did not reflect the resident's current condition and care needs. 2. Resident 48's written nutrition care plan was revised without a nursing assessment (cross reference F 692). These failures had the potential to affect the delivery of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident safety for two of 4 residents investigated for falls (90 and 7), and did not do a smoking safety assessment or provide education for Resident 155, when: 1. The facility did not document a change of condition for Resident 90 after 2 separate falls or initiate an Interdisciplinary Team (IDT) for either fall to investigate or assess the resident after those falls. 2. The facility did not implement a physician's order for landing mats for Resident 7, who was at risk for falls. 3. The facility did not ensure Resident 155 was educated and assessed for safe smoking before allowing the resident to smoke. In addition, Resident 155 was in possession of a lighter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 21 residents (Resident 48) who had severe weight loss was provided assistance with feeding as it was indicated on the resident's comprehensive assessment and the resident's written plan of care. As a result of this deficient practice, there was the potential for Resident 48 to experience further weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they had a physician's order to administer oxygen for one resident, Resident 41. As a result, Resident 41 was at risk for harm from over oxygenation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the pharmacy provided two routine medications for one randomly sampled resident (40) identified during medication pass observation. As a result, Resident 40 did not receive two of her morning medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the target behaviors monitored for the use of Antipsychotic medication were clear and specific for one of five residents (90) selected for an unnecessary medication review. Antipsychotic medications control psychotic symptoms such as delusions, hallucinations, and unstable moods. This failure had the potential for inconsistent behavior monitoring and could affect the ordering physician's ability to determine the effectiveness of the medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication error rate for medication pass observation did not exceed five percent. There were 35 opportunities, two medication errors were identified. The error rate was 5.7 percent.

Inspectors wroteBased on interview and record review the facility failed to ensure a physician's order for laboratory tests were carried out for one of 21 sampled residents (Resident 11). As a result, there could have been a delay in identifying abnormal lab values.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their Infection Prevention Program, when a Licensed Nurse (LN) 81 did not disinfect the vital sign machine between residents (8, 40). This failure had the potential to spread infections between residents.

Inspectors wroteBased on interview and record review, the facility failed to fully implement its antibiotic stewardship program for one of 5 residents (40) observed during medication administration. Resident 40 was on continuous antibiotic therapy without a clear indication. This failure could potentially increase the risk to Resident 40 for adverse side effects or the development of multi-drug resistant organisms (germ not killed by antibiotics).