A list of the most recent deficiencies for Victoria Care 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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2024-01-09 | 2024-01-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-07-21 | 2023-08-10 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2023-07-14 | 2023-08-09 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-06-13 | 2023-06-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-04 | 2022-08-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-10-28 | 2022-01-12 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-10-28 | 2022-01-12 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-28 | 2022-01-12 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2021-10-28 | 2022-01-12 | N |
| Ensure a qualified health professional conducts resident assessments. | Health | 2021-10-28 | 2022-01-12 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-10-28 | 2022-01-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-28 | 2022-01-12 | N |
| Post nurse staffing information every day. | Health | 2021-10-28 | 2022-01-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-10-28 | 2022-01-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-10-28 | 2022-01-12 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-28 | 2022-01-12 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-10-28 | 2022-01-12 | 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 | 2019-08-29 | 2019-09-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-08-29 | 2019-09-24 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-08-29 | 2019-09-24 | N |
| Post nurse staffing information every day. | Health | 2019-08-29 | 2019-09-24 | 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 | 2019-08-29 | 2019-09-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-29 | 2019-09-24 | N |
| Keep all essential equipment working safely. | Health | 2019-08-29 | 2019-09-24 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-08-29 | 2019-09-24 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-08-29 | 2019-09-24 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2019-09-05 | 2019-09-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-09-05 | 2019-09-23 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-09-05 | 2019-09-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-10-23 | 2018-11-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-10-23 | 2018-11-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-10-23 | 2018-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-10-23 | 2018-11-14 | 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 | 2018-10-13 | 2018-11-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2018-10-13 | 2018-11-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-13 | 2018-11-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-10-13 | 2018-11-09 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2018-10-13 | 2018-11-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-13 | 2018-11-09 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-10-13 | 2018-11-09 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-10-13 | 2018-11-09 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-10-13 | 2018-11-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-13 | 2018-11-09 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-10-13 | 2018-11-09 | N |
