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.

• No harm, potential for more than minimal, widespreadF812Jun 25, 2026

  Based on observation, interview, and record review, the facility failed to ensure the observance of proper sanitation and food handling practices when dietary aid (DA 1) failed to use a beard net during food handling.This failure had the potential to result in foodborne illnesses among the residents.During an observation, on 6/22/26, at 9 a.m., in the kitchen, a dietary aid (DA 1), was observed sporting a goatee (a style of facial hair defined by a small, pointed, or tufted beard grown entirely on the chin). The goatee measured approximately 1 to 2 inches in length. Additionally, DA 1 had noticeable stubble on both cheeks and upper lip. DA 1 was not wearing a beard net. When asked why he was not wearing a beard net, DA 1 stated, I forgot. […]

• No harm, potential for more than minimal, patternF656Feb 27, 2025

  Based on observation, interview and record review the facility failed to ensure: 1. Care plan interventions were implemented for three of 38 sampled resident's (Residents 61, 123 and 138). 2. Medication administration and interventions were completed as identified in the care plan for one of 38 sampled residents (Resident 682). 3. Consistent turning and repositioning of one of 38 sampled residents (Resident 5). 4. A snack was provided during Dialysis (treatment that removes waste and excess fluid from the body) days for one of 38 sampled residents (Resident 36). 5. Pillows were placed to offload pressure from heels for one of 38 sampled residents (Resident 121). This failure had the potential to result in the needs of residents not being met. Findings: 1. […]

• No harm, potential for more than minimal, isolatedF658Aug 28, 2026

  Based on interview and record review, the facility failed to follow physician orders for bowel-management medications for one of three sampled residents (Resident 1) when licensed nursing staff continued to administer multiple bowel-regimen medications despite documentation that the resident was experiencing loose stools and/or diarrhea and physician orders directing staff to hold the medications when loose stools or diarrhea occurred. This deficient practice resulted in Resident 1 receiving bowel-regimen medications contrary to prescribed hold parameters while experiencing ongoing loose stools and/or diarrhea, placing the resident at risk for worsening diarrhea, dehydration, electrolyte imbalance, skin impairment, and other related complications. […]

• No harm, potential for more than minimal, isolatedF657Jun 25, 2026

  Based on record review and interview, the facility failed to ensure the plan of care (POC) for respiratory (breathing) condition and a wound infection isolation protocols were accurately reflected for two (2) of 35 sampled residents (Resident 1 & 146) when:Resident 1 use of suction machine to remove excess oral secretions (fluids).Resident 146 was placed both for contact isolation precautions and enhanced barrier precautions.This failure had the potential to hinder continuity of care, insufficient management of residents' needs and not to address all aspects of residents' condition including the infection control protocols without the updated and accurate information of the care plan.Findings:1.During an observation and Resident 1's caregiver interview on 6/23/26, at 1:58 p.m. […]

• No harm, potential for more than minimal, isolatedF755Jun 25, 2026

  Based on observation, interview, and record review, the facility failed to ensure an extended-release medication (medication formulated to release its active ingredients slowly into the bloodstream over a prolonged period) was administered accurately in accordance with written orders of the attending physician for one of 35 sampled residents (Resident 127). This failure had the potential to alter the absorption of the medication and can increase the risk of side effects and overdose.During a review of Resident 127's admission Record (AR), the AD indicated Resident 127 was admitted to the facility on [DATE] with diagnoses that include heart failure (condition where the heart muscle cannot pump enough blood to meet the body's needs for blood and oxygen), chronic kidney disease (condition… […]