Deficiency Records for Victoria Post Acute Care
Updated as of January 01, 2022
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? |
|---|---|---|---|---|
| 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 appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-03-03 | 2020-03-31 | 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 |
| 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 |
| 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 |
| 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 a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | 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 |
| 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 | 2017-09-27 | 2017-10-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-09-27 | 2017-10-25 | N |
| Have properly sized and located compartments to protect residents from smoke. | Fire Safety | 2017-09-27 | 2017-10-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2017-09-27 | 2017-10-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-09-27 | 2017-10-25 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-09-27 | 2017-10-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2017-09-27 | 2017-10-25 | N |
