Victorian Village HLTH & Well

In the surveyor’s words

From the most serious findings on record at Victorian Village HLTH & Well, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 26, 2026

  Based on observation, interview, and record review, the facility failed to follow the transfer method recommended by physical therapy and indicated in the resident's plan of care. This failure resulted in R1 sustaining a 12cm (centimeter) left lower leg laceration, transfer to the hospital, and laceration repair with 21 sutures.This applies to 1 resident (R1) reviewed for safe transfers in a sample of 4.The findings include:On 3/24/2026 at 1:24 PM, R1 was in bed with a gauze wrap on her left leg.On 3/24/26 at 4:07 PM, V5 (CNA/Certified Nurse Assistant) said on 3/4/26 V12 (CNA) asked her to assist with transferring R1. V5 said prior to the transfer, R1's wheelchair was next to her bed, facing the head of the bed, with R1's left leg next to the bed. […]

• Actual harm, isolatedF686Jun 24, 2021

  Based on observation, interview and record review, the facility failed to assess for pressure relief a resident who was wearing a foot enclosed in an orthotic boot. This failure resulted to the resident sustaining unstageable pressure ulcer in the left heel. This applies to 1 of 3 residents (R42) reviewed for pressure ulcer in the sample of 12. The findings include: Face sheet indicate that R42 is [AGE] years-old, she has multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission note showed that R42 was admitted to the facility on [DATE] wearing an orthotic boot on the left foot. MDS (minimum data set) dated 6/12/21 indicated that R42 is alert and oriented and requires extensive assistance for bed mobility, locomotion, dressing toileting and personal hygiene. […]

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

  Based on observation, interview and record review the facility failed to maintain the kitchen facility in a manner to prevent foodborne illness. This applies to all 46 residents in the facility receiving dietary services. Findings include: On [DATE] at 3:42 PM V2 DON (Director of Nursing) confirmed on [DATE] all 46 residents of the facility received dietary services. On [DATE] at 10:08 AM, the facility main kitchen was toured with V9 Director of Dining Services. Dust was covering the vents over the stove. Open pots of food were cooking on the stove. Large Refrigerator- Zipped bag of 3 hot dogs dated [DATE]. Ham loosely wrapped with plastic wrap open and exposed dated [DATE]. Raw ground beef 10lb chub open end covered by plastic wrap meat gray. […]

• No harm, potential for more than minimal, widespreadF887Sep 13, 2024

  Based on interview and record review, the facility failed to offer COVID-19 vaccines to the facility's staff members and failed to provide education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine. This has the potential to affect all residents at the facility. Findings include: On 09/11/24 at 01:06 PM, V2 DON (Director of Nursing) said that he did not have any documentation to provide that the facility is offering the staff the COVID-19 vaccine or offering education about it. V2 said that the facility doesn't offer it anymore because it is too expensive. […]

• No harm, potential for more than minimal, widespreadF812Aug 31, 2023

  Based on observation, interview and record review, the facility failed to store pots and pans in a sanitary manner and failed to discard dented cans. This applies to all 49 residents that reside in the facility. The findings include: Facility Resident Census and Conditions of Residents form (CMS Form 672) dated August 28, 2023, showed that the facility census was 49. Facility gave verbal confirmation that 48 residents received oral diets and one resident was on dual (oral and tube) feedings. On August 28,2023 at 9:41 AM, during the initial tour of kitchen, the dish room had multiple cleaned pots and pans inverted on trays that were placed on a free-standing rack. These trays were noted to have marked miscellaneous debris, dust and unknown dried stains or spills. […]