Victoria Haven Nursing Facility

In the surveyor’s words

From the most serious findings on record at Victoria Haven Nursing Facility, in the surveyor’s own words.

• Actual harm, isolatedF580Feb 29, 2024

  Based on interview and record review, the facility failed to notify the physician of a change in the resident's physical, mental, or psychosocial status for one Resident (#11), out of a total sample of 12 residents. Specifically, the facility failed to notify the physician of the inability to obtain a urine sample for Resident #11's urinalysis culture and sensitivity (UA C&S) on two occasions: (1) 9/5/23 through 9/18/23 (14 days before the provider was notified and the order was discontinued) and (2) 10/27/23 through 12/8/23 (42 days before the resident was sent to the hospital), resulting in the progression of symptoms and the Resident being hospitalized for five days with pyelonephritis (kidney infection) and nephrolithiasis (kidney stone), requiring a peripherally inserted midline… […]

• Actual harm, isolatedF684Feb 29, 2024

  Based on record review, policy review, and staff interview, the facility failed to promote and manage the delivery of safe nursing care in accordance with accepted Standards of Nursing Practice by failing to identify and address a change in condition and provide necessary care and treatment for one Resident (#11), out of a total sample of 12 residents. Specifically, the facility failed to monitor, identify, and notify the physician of a change in condition resulting in Resident #11 being hospitalized for five days with pyelonephritis (kidney infection) and nephrolithiasis (kidney stone), requiring a peripherally inserted midline catheter for intravenous (IV) antibiotics. […]

• No harm, potential for more than minimal, widespreadF727Jan 21, 2026

  Based on record review and interview, the facility failed to utilize the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, as required placing all residents at risk for not having their clinical needs met either directly by the RN or indirectly by the Licensed Practical Nurse (LPN) or Certified Nurse Aides (CNA) that the RN was responsible for overseeing with provision of resident care. Specifically, the facility failed to provide the services of an RN for at least eight consecutive hours a day, seven days a week when no staffing waivers were in place on 4 of 92 days during the period of 7/1/25 through 9/30/25. […]

• No harm, potential for more than minimal, widespreadF730Jan 21, 2026

  Based on employee record review and interview, the facility failed to complete performance reviews of Certified Nursing Assistants (CNAs) at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five out of five CNA (#1, #2, #3, #4, #5) employee records reviewed. Findings include:Review of five out of five personnel files, of CNAs (#1, #2, #3, #4, #5) who had been employed by the facility for over 12 months, failed to indicate a performance evaluation was completed in 2025. During an interview on 1/21/26 at 12:19 P.M., the Director of Nursing said he has been employed at the facility just over a year. […]

• No harm, potential for more than minimal, widespreadF867Jan 21, 2026

  Based on interview and record review, the facility failed to develop, implement and maintain a Quality Assurance and Performance Improvement (QAPI) program which focuses on indicators of outcomes of quality of life, quality of care, and services to residents in the facility. Specifically, the facility failed to show evidence of implementing a data driven QAPI plan for clinical measures, quality of life, and resident choices identified by the facility to improve the resident's quality of life. […]