Deficiency Records for Victoria Post Acute Care
Updated as of February 01, 2020
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? |
|---|---|---|---|---|
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-07-11 | 2019-07-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-19 | 2019-07-24 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2019-06-19 | 2019-07-24 | Y |
| 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 |
| 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 |
| 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 ne | 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 |
| 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 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-08-03 | 2018-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2018-08-03 | 2018-08-28 | Y |
| Provide appropriate foot care. | Health | 2018-03-07 | 2018-03-28 | Y |
| 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 | 2018-02-07 | 2018-03-06 | Y |
| 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 | 2017-11-17 | 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 | 2017-11-17 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-09-22 | 2017-11-17 | N |
| Maintain comfortable and safe temperature levels. | Health | 2017-09-22 | 2017-11-17 | 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 | 2017-11-17 | N |
| Allow residents the right to participate in the planning or revision of care and treatment. | Health | 2017-09-22 | 2017-11-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2017-09-22 | 2017-11-17 | 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 | 2017-11-17 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-09-22 | 2017-11-17 | N |
| Dispose of garbage and refuse properly. | Health | 2017-09-22 | 2017-11-17 | 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 | 2017-11-17 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-09-22 | 2017-11-17 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-09-22 | 2017-11-17 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-09-22 | 2017-11-17 | 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 | 2017-11-17 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-09-22 | 2017-11-17 | 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 |
| 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 |
| 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 |
| Ensure services provided by the nursing facility meet professional standards of quality. | 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 |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | 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 |
| Have a program that investigates, controls and keeps infection from spreading. | 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 |
