Victoria Crossing Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF880Sep 5, 2024

  Based on observations, interview, and record review the facility failed to ensure proper infection control practices were in place on one out of four units related to proper personal protective equipment (PPE) use, timeliness of contact precaution orders, and hang hygiene. Findings included: An observation was conducted on 9/5/24 at 9:46 a.m. of Staff E, Registered Nurse (RN) during medication administration. Upon exiting a resident room after administering mediation, Staff E did not perform hand hygiene. The nurse proceeded to the medication cart, touched the computer and other items on the cart. An observation was conducted on 9/5/24 at 10:03 a.m. of a visitor in the room of Resident #11. The room had a Contact Precaution sign on the door and the visitor had on no PPE. […]

• No harm, potential for more than minimal, isolatedF554Jan 8, 2026

  Based on observations, record reviews, and interviews the facility failed to ensure two (#25 and #19) of two residents reviewed for self administration of medications were assessed by the facility and a physician order was obtained to allow for the self-administration of medications related to the administration of oral and nebulized medications.Findings included: On 1/6/26 at 10:08 a.m. Resident #25 was observed lying in bed with an over-bed table within reach of the resident. A medication cup containing 10 oral tablets was sitting in the corner of the table within reach of the resident. The resident reported just getting the medication and would take them. Resident #25 reached over to the table, retrieved the cup, and swallowed all of the tablets at one time. […]

• No harm, potential for more than minimal, isolatedF561Jan 8, 2026

  Based on observation and interview, the facility failed to provide Meal Menus to four (Resident #24, Resident #67, Resident #105 and Resident #110) out of four residents reviewed for choices.Findings Included: During an interview on 01/05/2026 at 9:27 a.m., Resident #24 stated they have not passed out menus in a while, so she has no idea what she is getting to eat until they bring the trays in. An observation of Resident #24's wall and overside table revealed no meal menu. During an interview on 01/05/2025 at 10:02 a.m., Resident #67 stated they don't pass out menus anymore, so I never know what they are bringing me to eat. They will bring my tray, and I can order something else, but I cannot order it ahead of time since I don't know what they are serving. […]

• No harm, potential for more than minimal, isolatedF627Jan 8, 2026

  Based on record review and interview, the facility failed to allow the resident to remain in the facility during a pending appeal for one resident (#133) out of four residents reviewed for discharge.Findings Included:Review of Resident #133's admission record revealed an admission date of 10/01/2025 and a discharge date of 11/04/2025. Resident #133 was admitted to the facility with diagnosis to include orthopedic aftercare following surgical amputation, other acute osteomyelitis, left ankle and foot, chronic obstructive pulmonary disease, and muscle weakness.Review of a care plan for Resident #133 initiated on 10/03/2025 revealed a focus; [Resident #133] wishes to return home with her [family member]. […]

• No harm, potential for more than minimal, isolatedF628Jan 8, 2026

  Based on record review and interview, the facility failed to document the required discharge/transfer notifications and the reason for discharge for one resident (#133) out of four residents reviewed for discharge.Findings Included:Review of Resident #133's admission record revealed an admission date of 10/01/2025 and a discharge date of 11/04/2025. Resident #133 was admitted to the facility with diagnosis to include orthopedic aftercare following surgical amputation, other acute osteomyelitis, left ankle and foot, chronic obstructive pulmonary disease, and muscle weakness. Review of Resident #133's electronic medical record revealed revealed no documentation regarding required elements for discharge per policy.An interview was conducted on 01/08/2026 at 3:56 p.m. […]