Deficiency Records for Victoria Post Acute Care
Updated as of March 01, 2018
This is not the most recent data for Victoria Post Acute Care. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-01-08 | 2018-01-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-01-08 | 2018-01-23 | Y |
| Keep each resident free from physical restraints, unless needed for medical treatment. | Health | 2017-09-22 | 2017-11-15 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-09-22 | 2017-11-15 | N |
| Maintain comfortable and safe temperature levels. | Health | 2017-09-22 | 2017-11-15 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-09-22 | 2017-11-15 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-09-22 | 2017-11-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-22 | 2017-11-15 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2017-09-22 | 2017-11-15 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-22 | 2017-11-15 | N |
| Dispose of garbage and refuse properly. | Health | 2017-09-22 | 2017-11-15 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2017-09-22 | 2017-11-15 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-22 | 2017-11-15 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-22 | 2017-11-15 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-22 | 2017-11-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2017-09-22 | 2017-11-15 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-22 | 2017-11-15 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-09-20 | 2017-11-01 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-05-26 | 2017-05-31 | Y |
| Provide residents with private access to a telephone. | Health | 2016-12-22 | 2017-01-06 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-11-07 | 2016-12-04 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-07 | 2016-12-04 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-11-04 | 2016-12-04 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2016-08-23 | 2016-09-16 | Y |
| Approved construction type or materials. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Exits that are accessible at all times. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Rooms that can be unlocked from inside without a key. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Properly located and lighted "Exit" signs. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| An approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Properly protected cooking facilities. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Weekly inspections and monthly testing of generators. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Properly installed electrical wiring and equipment. | Fire Safety | 2016-06-29 | 2016-08-11 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-07-08 | 2016-08-08 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-07-08 | 2016-08-08 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2016-06-23 | 2016-07-18 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-06-23 | 2016-07-18 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-06-23 | 2016-07-18 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-06-23 | 2016-07-18 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-06-23 | 2016-07-18 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-06-23 | 2016-07-18 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-06-23 | 2016-07-18 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-06-23 | 2016-07-18 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-06-23 | 2016-07-18 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-06-23 | 2016-07-18 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-06-23 | 2016-07-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2016-06-23 | 2016-07-18 | N |
| Have a detailed, written plan for disasters and emergencies, such as fire, severe weather, and missing residents. | Health | 2016-06-23 | 2016-07-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-06-23 | 2016-07-18 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-06-23 | 2016-07-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2015-12-30 | 2016-01-17 | Y |
| Keep all essential equipment working safely. | Health | 2015-12-30 | 2016-01-17 | Y |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2015-07-28 | 2015-09-11 | N |
| Automatic sprinkler systems that have been maintained in working order. | Fire Safety | 2015-07-28 | 2015-09-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2015-07-09 | 2015-08-08 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2015-07-09 | 2015-08-08 | N |
| Provide activities to meet the interests and needs of each resident. | Health | 2015-07-09 | 2015-08-08 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-07-09 | 2015-08-08 | N |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2015-07-09 | 2015-08-08 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-07-09 | 2015-08-08 | N |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2015-07-09 | 2015-08-08 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-07-09 | 2015-08-08 | N |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2015-07-09 | 2015-08-08 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2015-07-09 | 2015-08-08 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-07-22 | 2015-08-04 | Y |
