Victoria Nursing & Rehabilitation Center, Inc.

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF684Jun 18, 2026

  Based on observation, interview and record review, the facility failed to ensure positioning devices were in place as prescribed for two (Resident #184 and Resident # 240).out of thirty-six sampled residents as evidenced by Residents #184 and Resident # 240 were found in bed without their ordered heel protectors. The facility had 311 residents at the time of the survey. The findings included: On 06/15/2026 at 8:57 AM Resident #184 was observed asleep in bed, bilateral heel protectors were noted at the foot of the bed (Photographic evidence).On 06/16/2026, at 9:14 AM, Resident #184 was observed seated in wheelchair participating in activities on the fifth floor. […]

• No harm, potential for more than minimal, isolatedF689Jun 18, 2026

  Based on observations, records reviewed and interviews, it was determined that the facility did not maintain adequate supervision to ensure a safe environment that is free from accident and hazards as evidenced by one (Resident #48) out of five residents who smoked was observed removing a lighter that he kept in his pocket. There were 311 residents residing in the facility at the time of the survey. The findings included: Observation on 06/17/2026 at 10:36 AM revealed Resident #48 seated in a wheelchair wearing a smoking apron while he smoked outside in the facility's designated smoking area, the resident reached into his pocket and took out a lighter. […]

• No harm, potential for more than minimal, isolatedF695Jun 18, 2026

  Based on observation, interview and record review the facility failed to administer oxygen therapy as ordered for two out of twenty-six residents receiving oxygen (Resident #23 and Resident # 329). As evidenced by Resident # 23's oxygen concentrator was observed at 2.5 Liters Per Minute (LPM) instead of 3 LPM and Resident # 329's oxygen concentrator was being delivered at 1.5 LPM instead of 2 LPM. The findings included: Observations on 06/15/2026 at 8:27 AM and on 06/16/2026 at 8:26 AM revealed Resident #23 receiving oxygen (02) running at 2.5 Liters Per Minute (LPM) via Nasal Canula (NC) (photographic evidence).On 06/17/2026, at 9:52 AM, Resident #23 was observed awake in bed, receiving oxygen at 3 LPM via nasal cannula.Review of Resident #23's clinical records revealed the resident was… […]

• No harm, potential for more than minimal, isolatedF761Jun 18, 2026

  Based on observations, record review and interviews, the facility failed to provide safe and secure storage of biologicals for five (Resident #31, Resident #184, Resident #202, Resident #224 and Resident #240) out of thirty-six sampled residents. There were 311 residents residing in the facility at the time of the survey. The findings included. Observation on 06/15/2026 at 8:15 AM in Resident # 31's room revealed one tube of toothpaste, and one bottle of body wash were noted on the resident's dresser draped with a clear plastic bag. (photographic evidence). […]

• No harm, potential for more than minimal, isolatedF867Jun 18, 2026

  Based on observations, interview and record review, the facility's quality assurance and assessment committee failed to demonstrate an effective plan of action was implemented to correct identified quality deficiencies in the problem area related to repeated deficient practice for F695- Respiratory/Tracheostomy care and Suctioning, F761- Label/Store Drugs & Biologicals. There were 311 residents residing in the facility at the time of the survey. The findings included: Record review of the facility's survey history revealed, during a Recertification Survey conducted on December 09, 2024, through December 12, 2024, at the facility. F695 Respiratory/Tracheostomy care and Suctioning was cited as the facility failed to administer oxygen as ordered for one (1) Resident. […]