A list of the most recent deficiencies for Victorian Post Acute. 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? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-04-21 | 2023-06-02 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-04-21 | 2023-06-02 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-04-21 | 2023-06-02 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-04-21 | 2023-06-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-04-21 | 2023-06-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-21 | 2023-06-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-21 | 2023-06-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-21 | 2023-06-02 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-04-21 | 2023-06-02 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-04-21 | 2023-06-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-21 | 2023-06-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-21 | 2023-06-02 | 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 | 2023-04-21 | 2023-06-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-21 | 2023-06-02 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-04-21 | 2023-06-02 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-21 | 2023-06-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-21 | 2023-06-02 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-04-21 | 2023-06-02 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-04-21 | 2023-06-02 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-04-21 | 2023-06-02 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-24 | 2023-05-11 | 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 | 2023-04-24 | 2023-05-11 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-24 | 2023-05-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-10 | 2022-03-24 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-10 | 2022-03-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-10 | 2022-03-24 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-10 | 2022-03-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-08-23 | 2019-11-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-23 | 2019-11-07 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-08-23 | 2019-11-07 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-08-23 | 2019-11-07 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-08-23 | 2019-11-07 | N |
| Post nurse staffing information every day. | Health | 2019-08-23 | 2019-11-07 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2019-08-23 | 2019-11-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-08-23 | 2019-11-07 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2019-08-23 | 2019-11-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-23 | 2019-11-07 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-08-23 | 2019-11-07 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-08-23 | 2019-11-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Use approved construction type or materials. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-27 | 2019-10-15 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Develop a communication plan. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-11-28 | 2018-12-14 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-08-31 | 2018-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-31 | 2018-10-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-08-31 | 2018-10-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-08-31 | 2018-10-15 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-08-31 | 2018-10-15 | N |
