A list of the most recent deficiencies for Victoria Post Acute Care. 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-09 | 2023-07-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-28 | 2022-11-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-28 | 2022-11-17 | 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 | 2022-09-28 | 2022-11-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-28 | 2022-11-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-09-28 | 2022-11-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-28 | 2022-11-16 | 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 | 2022-09-28 | 2022-11-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-28 | 2022-11-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-28 | 2022-11-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-28 | 2022-11-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-28 | 2022-11-16 | 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 | 2022-09-28 | 2022-11-16 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-09-28 | 2022-11-16 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-09-28 | 2022-11-16 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-09-28 | 2022-11-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Use approved construction type or materials. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Meet other general requirements. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-09-27 | 2022-10-17 | N |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2022-08-05 | 2022-09-30 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-06-10 | 2022-07-08 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-10 | 2022-07-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-10 | 2022-07-08 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-01-19 | 2022-02-01 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-13 | 2021-10-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-25 | 2021-09-25 | Y |
| Provide primary/alternate means for communication. | Fire Safety | 2020-01-23 | 2020-02-10 | N |
| Use approved construction type or materials. | Fire Safety | 2020-01-23 | 2020-02-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-01-23 | 2020-02-10 | 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 | 2020-01-23 | 2020-02-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2020-01-23 | 2020-02-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-12-12 | 2020-01-07 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-12-12 | 2020-01-07 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-12-12 | 2020-01-07 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-11 | 2019-01-31 | N |
| Develop a communication plan. | Fire Safety | 2018-12-11 | 2019-01-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-12-11 | 2019-01-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-11 | 2019-01-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-12-11 | 2019-01-31 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-12-11 | 2019-01-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-11-08 | 2018-12-30 | 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 | 2018-11-08 | 2018-12-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-11-08 | 2018-12-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-11-08 | 2018-12-30 | 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 | 2018-11-08 | 2018-12-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-11-08 | 2018-12-30 | N |
| Provide activities to meet all resident's needs. | Health | 2018-11-08 | 2018-12-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-11-08 | 2018-12-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-11-08 | 2018-12-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-11-08 | 2018-12-30 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-11-08 | 2018-12-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-11-08 | 2018-12-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-11-08 | 2018-12-30 | 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 | 2018-11-08 | 2018-12-30 | 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 | 2018-11-08 | 2018-12-30 | 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 | 2018-11-08 | 2018-12-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-11-08 | 2018-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-11-08 | 2018-12-30 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-11-08 | 2018-12-30 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-11-08 | 2018-12-30 | N |
| Keep all essential equipment working safely. | Health | 2018-11-08 | 2018-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-26 | Not Fixed | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-26 | Not Fixed | N |
