Victorian Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF686Apr 21, 2023

  Based on observation, interview, and record review, the facility failed to provide preventive care and treatment to avoid worsening and development of additional pressure ulcer/injury (PU/PI - a localized damage to the skin and/or underlying soft tissue usually over a bony prominence, or related to a medical or other device, as a result of intense and/or prolonged pressure or pressure in combination with shear) on left medial toe (big toe); and promote healing of existing pressure injuries for one of 4 sampled residents (Resident 36) when: 1. The facility did not ensure complete and accurate wound assessment on admission that includes identification, measurement, and description of wound. […]

• Actual harm, isolatedF686Jan 10, 2022

  Based on observation, interview and record review, the facility failed to provide preventative care and treatment to avoid development and worsening of pressure ulcers for one of three sampled residents (Resident A). 1. There was no assessment and documentation of pressure ulcers on the following dates: Right buttock pressure ulcer #1: 9/24/21 through 10/6/21; and 11/4/21 Right buttock pressure ulcer #2: 9/24/21 through 10/6/21; 10/7/21; 10/14/21; 11/4/21; and 11/11/21 Left buttock pressure ulcer: 9/23/21 through 10/6/21 Left heel open wound: 9/30/21 through 10/6/21; and 11/24/21 2. Turning and repositioning was not done to ensure pressure reduction on the following dates: 9/26/21, 10/10/21, 10/21/21, 10/30/21, 11/7/21, 11/19/21, 11/20/21, 11/25/21 and 11/29/21. 3. […]

• No harm, potential for more than minimal, widespreadF812Apr 21, 2023

  Based on observation, interview and record review, the facility failed to store, prepare, and distribute food in a safe and sanitary manner when: 1.Packaged food items were not sealed close or secured after opening, had no use by dates, and not stored properly 2.A pitcher was stored wet in the pitcher cupboard 3.Kitchen trays and plate covers or domes were not maintained in good condition 4.Food storage containers and equipment found in the kitchen were not kept clean 5.Kitchen staff did not wear a hairnet in the kitchen 6.Cooling procedures of potentially hazardous foods was not followed (PHF, food that requires time/temperature control for safety to limit the growth of pathogenic microorganisms [such as bacterial or viral organisms] that can cause foodborne illness. […]

• No harm, potential for more than minimal, widespreadF814Apr 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed properly when: 1.The dumpster lids for garbage and recycled items were kept open 2.A facility staff did not close the dumpster lid after garbage bags were thrown into the garbage dumpster These failures could result in harborage and feeding of pests in the facility. Findings: 1. During a concurrent observation and interview on 4/18/23 at 9:51 AM, with the Kitchen Supervisor (KS) present, the dumpster site located in the garage area of the facility was inspected. The garbage dumpster lid was propped open by a wooden plank. The recycle dumpster lid was wide open. KS stated both dumpster lids for garbage and recyclables should be closed. […]

• No harm, potential for more than minimal, patternF698Apr 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure care and services were consistent with professional standards of care and the residents' comprehensive, person-centered care plan and preferences for 2 out of 2 residents (Resident 60 and Resident 23) who received hemodialysis [a treatment for advanced kidney failure where a machine filters wastes and water from the blood] at an offsite location when: 1.There was no interdisciplinary team (IDT) recommendation to monitor, document, and ensure nutrition and hydration needs related to provision of meals or snacks, including bagged meals were provided to residents before going to dialysis appointments 2.The dialysis care plans were not specific, individualized and implemented to ensure nutrition and hydration… […]