Victoria Care Center

In the surveyor’s words

From the most serious findings on record at Victoria Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF760Aug 4, 2022

  Based on interview and record review, the facility failed to follow its policy and procedure on Medication Orders, to prevent significant medication errors (medication errors that causes the resident discomfort or jeopardizes the resident health and safety) for one of three sampled residents (Resident 1) by failing to: 1. Ensure Registered Nurse 1 (RN 1) checked Resident 1's name on the Physician Admission Order (medication list) when she transcribed (to make a written copy)13 of the medication list into the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF580Oct 28, 2021

  Based on interview and record review, the facility failed to immediately notify the resident's physician and resident's family representative after one of 29 sampled residents (Resident 47) sustained an unwitnessed fall that occurred on 10/26/21, which resulted in the resident to experience severe pain, and a delay in timely treatment after twelve (12) hours. As a result, Resident 47 was transferred to the GACH (General Acute Care Hospital) where an x-ray (a photographic or digital image) report, indicated the resident had a comminuted (the bone breaks into several pieces) intertrochanteric fracture (breaks of the femur between the greater and the lesser trochanters [overhang toward the near end of the thighbone]). […]

• Actual harm, isolatedF689Oct 28, 2021

  Based on interview and record review, the facility failed to provide supervision with toileting (how a resident uses the toilet room) to prevent one of 29 sampled residents (Resident 47) from sustaining an unwitnessed fall (refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force). Resident 47 was at risk for falls due to intermittent confusion (not being able to think clearly or quickly, feeling disorientated, and struggling to pay attention, make decisions), balance problems while standing and walking, and required limited assistance (resident highly involved in activity, staff to provide guided maneuvering of limbs or other non-weight bearing assistance) with toileting. […]

• No harm, potential for more than minimal, patternF641Apr 9, 2026

  Based on interview and record review, the facility failed to ensure two of two sampled residents' (Residents 6 and 51) Minimum Data Set (MDS- standardized assessment and care planning tool) reflected an accurate assessment by failing to: a. Ensure Resident 51, who was discharged to home under the care of home health (wide range of health care services that can be given at home for an illness or injury) service was coded in the MDS assessment accurately.b. Ensure Resident 6's hearing impairment was coded in MDS assessment. […]

• No harm, potential for more than minimal, patternF656Apr 9, 2026

  Based on observation, interview, and record review, the facility failed to develop and implement specific, comprehensive, and individualized person-centered care plans to meet the residents' needs for three of three sampled residents (Residents 6, 31 and 38) by failing to: a. Implement Resident 31's care plan of turning and repositioning schedule every two (2) hours. b. Developed a care plan to address Resident 6's hearing loss and use of Gabapentin (a medication for nerve pain and used to control seizures). c. Developed a care plan to address Resident 38's current gastrostomy tube (GT, a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids, and medications) feeding formula. […]