Deficiency Records for Victoria Healthcare and Rehabilitation Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Victoria Healthcare and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-11-01 | 2023-12-05 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-11-01 | 2023-12-05 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-11-01 | 2023-12-05 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2023-11-01 | 2023-12-05 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-11-01 | 2023-12-05 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-01 | 2023-12-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-31 | 2023-11-19 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-10-31 | 2023-11-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-10-23 | 2023-11-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-28 | 2023-07-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-28 | 2023-04-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-03-28 | 2023-04-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-08 | 2022-12-08 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2022-10-04 | 2022-11-03 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-04 | 2022-11-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-04 | 2022-11-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-08 | 2022-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-26 | 2022-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-05 | 2021-09-05 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-09 | 2021-08-09 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-07-09 | 2021-08-09 | N |
| Assess the resident when there is a significant change in condition | Health | 2021-07-09 | 2021-08-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-09 | 2021-08-09 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-07-09 | 2021-08-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-09 | 2021-08-09 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-09 | 2021-08-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-07-09 | 2021-08-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-09 | 2021-08-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-09 | 2021-08-09 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-07-09 | 2021-08-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-07-12 | 2021-07-26 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-07-12 | 2021-07-26 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-07-12 | 2021-07-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-07-12 | 2021-07-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-07-12 | 2021-07-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-07-12 | 2021-07-26 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-09 | 2021-04-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-09 | 2021-04-27 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-10-09 | 2019-10-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-09 | 2019-10-23 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-09-12 | 2019-10-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-12 | 2019-10-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-12 | 2019-10-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-12 | 2019-10-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-12 | 2019-10-12 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-12 | 2019-10-12 | N |
| Keep all essential equipment working safely. | Health | 2019-09-12 | 2019-10-12 | N |
