Victoria Post Acute Care

In the surveyor’s words

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

• Actual harm, isolatedF580Sep 28, 2022

  Based on observation, interview and record review, the facility failed to immediately follow up on one of 21 residents (Resident 39) who, had a reported abnormally low blood pressure (When the pressure of circulation blood against the walls of blood vessels read below ,d+[DATE] mmHg). As a result, Resident 39 developed an acute change in condition (sudden clinically important deviation from a resident's baseline to prevent complications) which resulted in unresponsiveness and death. Findings: Resident 39 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial tour of the facility was conducted on [DATE] at 9:13 AM. Resident 39 was observed on [DATE] at 9:13 during the initial tour, seated in his wheelchair next to his bed. […]

• No harm, potential for more than minimal, widespreadF812Sep 13, 2024

  Based on observation, interview, and record review, the facility failed to ensure food safety and sanitation practices in dietary services were maintained for food storage according to standards of practice when: 1. One ice machine, and two three-compartment sinks did not have a proper air gap system to adequately prevent backflow of contaminated foods. 2. One facility prep sink was covered with white stained deposits, rust, and discolored raised pebble sized rock-like substance permanently embedded on the surface was being used. 3. The facility mixer for preparing food did not have a splash guard to prevent contaminating floor and kitchen equipment surfaces during use. 4. The facility did not safely prepare a meat recipe by using unpasteurized eggs. […]

• No harm, potential for more than minimal, patternF804Jan 29, 2026

  Based on observation, interview and record review, the facility failed to ensure food served to residents was plated with an appetizing presentation.This failure had the potential to lead to a negative dining experience, resulting in reduced appetite, weight loss and feelings of disappointment.Findings:On 1/26/26 at 8:29 A.M., an interview was conducted with Resident 100 in her room. Resident 100 stated the food could have a better presentation, sometimes the look on the plates don't look good, could be nicer.On 1/26/26 at 8:45 A.M., an interview was conducted with Resident 21 in her room. Resident 21 stated the food sometimes would be cold and presentation could be better. […]

• No harm, potential for more than minimal, patternF804Sep 13, 2024

  Based on observation, interview and record review, the facility failed to ensure food served was in a palatable, flavorful manner that maintained the nutritional value of the menu items served when: 1. Food complaints were not being addressed appropriately. 2. The recipe was not followed during the preparation for a meat recipe. Cross-reference (F812) This failure had the potential to decrease residents' meal intake and contribute to weight loss. The facility census was 110. Findings: 1. A document review was conducted on 9/10/24 at 9:57 A.M., of the facilities policy titled Meal Service indicated 1. Meal times . Lunch at 11:00-12:30 P.M . An interview was conducted on 9/10/24 at 11:28 A.M., with the licensed nurse (LN) 1. […]

• No harm, potential for more than minimal, patternF880Sep 13, 2024

  Based on observations, interviews, record reviews the facility failed to provide a safe, sanitary (clean), and comfortable environment to help prevent highly contagious infections when: 1. Facility did not store respiratory equipment properly for Resident 261. 2. Licensed Nurses (LN) did not have interventions in place to clean Resident 33's continuous positive airway pressure (CPAP) mask according to professional standards of practice. 3. Three certified nursing assistants (CNA) did not practice infection control protocols with hand hygiene and/or the use of protective personal equipment (PPE: clothing or equipment that protects people from injury or infection in the workplace) for residents (Resident 45, Resident 95, and Resident 108) on transmission-based precautions. […]