Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
51 residents
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Annual Inspection
Census: 51
Deficiencies: 2
Aug 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with care plan implementation and resident safety protocols, specifically focusing on fall prevention measures for residents at risk.
Findings
The facility failed to implement a fall care plan for Resident #7, who was found unattended in a high positioned bed with only one floor mat instead of the ordered bilateral mats. This increased the resident's risk of falling and sustaining severe injuries. Staff acknowledged removing one floor mat and raising the bed for body mechanics but left the resident unsupervised, contrary to facility policy.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to implement a fall care plan for Resident #7, leaving the resident unattended in a high positioned bed with only one floor mat instead of bilateral mats as ordered. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide an environment free from accident hazards and adequate supervision to prevent accidents for Resident #7 at risk for falls. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents on third floor: 51
Fall history timeframe: 2
Fall history timeframe: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Named in findings related to leaving Resident #7 unattended in a high positioned bed and removing one floor mat |
Inspection Report
Annual Inspection
Census: 307
Deficiencies: 4
Dec 12, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements including privacy, pre-admission screening, respiratory care, medication storage, and other care standards.
Findings
The facility was found deficient in maintaining resident privacy during medication administration, ensuring accurate and timely pre-admission screening and resident review (PASRR), providing safe and appropriate respiratory care by administering oxygen as ordered, and properly storing medications at bedside. Deficiencies were noted with minimal harm or potential for actual harm affecting a few residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to provide privacy on medication cart computer screens and during medication administration for Resident #57. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate Level I PASRR was completed timely for two residents (Resident #254 and Resident #266). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to administer oxygen as ordered for Resident #244, observed without nasal cannula resulting in decreased oxygen saturation. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store medications at bedside for four residents (Resident #254, #6, #21, and #163). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents: 307
Residents sampled: 12
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse (LPN) | Named in privacy deficiency related to medication cart computer screen |
| Staff C | Registered Nurse (RN) | Named in privacy deficiency related to medication administration for Resident #57 |
| Staff B | Registered Nurse (RN) | Named in oxygen administration deficiency for Resident #244 |
| Staff G | Registered Nurse (RN) | Named in medication storage deficiency related to nasal spray removal |
| Staff E | Registered Nurse (RN) | Named in medication storage deficiency related to medication at Resident #21's nightstand |
| Staff J | Advanced Practice Registered Nurse (APRN) | Interviewed regarding PASRR process and oxygen administration |
| Staff J | Certified Nursing Assistant (CNA) | Interviewed regarding oxygen administration protocol for Resident #244 |
| Staff D | Assistant Director of Nursing (ADON) | Interviewed regarding medication storage policy |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding privacy, oxygen administration, and medication storage policies |
| Director of Social Services | Director of Social Services | Interviewed regarding PASRR process and diagnosis omissions |
Inspection Report
Routine
Census: 303
Deficiencies: 5
Jul 20, 2023
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident assessments, pharmaceutical services, medication administration, and quality assurance processes.
Findings
The facility failed to accurately code a resident's Minimum Data Set (MDS) discharge status, ensure proper pharmaceutical procedures during medication administration for two residents, and maintain medication cart security. The medication error rate was 5.71% during observed medication administrations. The facility also demonstrated deficiencies in implementing effective corrective plans for repeated pharmacy service issues.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to accurately code a minimum data set (MDS) discharge status for one resident, incorrectly coding discharge to an acute hospital instead of a rehabilitation center. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure pharmaceutical procedures were followed during medication administration for two residents, including a missed dose and improper medication dispensing. | Level of Harm - Minimal harm or potential for actual harm |
| Medication cart electronic screen was left unlocked and unattended. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rates were below 5 percent, with an observed error rate of 5.71 percent during medication administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to demonstrate effective quality assurance and corrective action plans to address repeated pharmacy service deficiencies. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 303
Medication administration opportunities observed: 35
Medication errors observed: 2
Medication error rate: 5.71
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | MDS Coordinator | Interviewed regarding incorrect MDS coding for Resident #299 and correction of the error |
| Staff B | Registered Nurse | Observed medication administration and discussed medication reorder process for Resident #233 |
| Staff C | Registered Nurse | Observed leaving medication cart unlocked and acknowledged the error |
| Staff D | Registered Nurse | Observed medication administration error for Resident #92 and discussed with ADON |
| Staff E | Assistant Director of Nursing (ADON) | Discussed medication error and corrective actions with Staff D |
| Staff F | Nursing Supervisor | Discussed medication order changes and blister pack replacement for Resident #92 |
| Staff G | Pharmacist | Interviewed about medication orders and administration for Resident #92 |
| ADON/QAPI | Assistant Director of Nursing / Quality Assurance Performance Improvement | Described QA/QAPI meetings and corrective action processes |
Inspection Report
Annual Inspection
Deficiencies: 0
Jun 13, 2023
Visit Reason
The inspection was conducted as an annual survey of Victoria Nursing & Rehabilitation Center, Inc. to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 299
Deficiencies: 8
Jun 24, 2022
Visit Reason
Routine inspection of Victoria Nursing & Rehabilitation Center, Inc. to assess compliance with regulatory requirements including resident care, medication administration, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure call lights were within reach for residents at risk of falls, improper use of physical restraints, failure to follow care plans for residents with contractures, inadequate supervision to prevent accidents, improper respiratory care, pharmaceutical service deficiencies including medication administration errors, and improper food storage practices.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 8
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to ensure call light was within reach for Resident #284 who had a fractured left arm and was at risk for falls. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure Resident #357 was free from physical restraints as evidenced by use of hand mitten without physician order. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to develop and implement a complete care plan for Resident #284 and Resident #131 related to fall risk and use of hand rolls for contractures. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide adequate supervision and ensure call light was consistently in reach for Resident #284 who sustained multiple falls including one resulting in fracture. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide respiratory care consistent with professional standards for Residents #24 and #296 as oxygen concentrator settings were not at prescribed rates and nasal cannulas were not properly applied. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide pharmaceutical services to meet the needs of residents including crushing medications that should not be crushed, improper medication disposal, and failure to reconcile controlled substances. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store food under sanitary conditions as employee lunch bags were stored in nourishment room refrigerators with resident food and were not labeled or dated. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to demonstrate effective quality assurance and performance improvement actions to correct repeated deficiencies related to pharmacy services and medication administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents present: 299
Residents sampled: 38
Fall scale: 65
Oxygen flow rate: 3.5
Oxygen flow rate: 4
Oxygen flow rate: 1.5
Oxygen flow rate: 2
Medication counts: 5
Medication counts: 53
Medication counts: 25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Certified Nursing Assistant | Interviewed regarding Resident #284's fall risk and call light placement |
| Staff N | Registered Nurse | Interviewed regarding Resident #284's fall risk and supervision |
| Staff O | Registered Nurse | Interviewed regarding Resident #131's hand roll use |
| Staff P | Certified Nursing Assistant | Interviewed regarding Resident #131's hand roll use |
| Staff Q | Nurse | Interviewed regarding nourishment room refrigerator use |
| Staff F | Assistant Director of Nursing and Compliance Officer | Interviewed regarding quality assurance and corrective actions |
| Staff D | Registered Nurse, Unit 7 floor Supervisor | Interviewed regarding oxygen therapy compliance |
| Staff E | Registered Nurse, Unit 7 south unit | Interviewed regarding oxygen therapy monitoring |
| Staff J | Registered Nurse | Observed crushing medications during administration |
| Staff K | Licensed Practical Nurse | Observed breaking tablets with bare hands during medication administration |
| Staff C | Registered Nurse | Interviewed regarding narcotic medication count discrepancies |
| Staff A | Registered Nurse | Observed discarding medication improperly and interviewed about medication disposal |
| Staff G | Assistant Director of Nursing | Conducted in-service education on medication disposal |
| Staff R | Occupational Therapist | Interviewed regarding Resident #131's hand roll and splint orders |
| Staff S | RN Restorative Nursing | Interviewed regarding Resident #131's hand roll care plan |
| Staff T | Registered Dietitian | Interviewed regarding nourishment room refrigerator use |
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