Victoria's Place

Regular observation and documentation of resident changes

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental..., the licensee shall ensure that such changes are documented & brought to the attention of the resident's physician and the resident's responsible person, This requirement has not been met as evidence by: Based on LPA’s records review and interviews with the Licensee, LPA learned that Licensee failed to obtain an updated physician’s report (LIC602) for R1 after they have a significant change of condition and ambulatory status, which poses a potential risk to the health and safety of the residents in care.

Call 9-1-1 for imminent health threats

87465 Incidental Medical and Dental Care (g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis...This requirement has not been met as evidence by: Based on interviews conducted with facility staff and records reviews of fire department service calls, the facility staff failed to seek medical attention after observing R1’s significant change of condition at 7:30am, which poses an immediate risk to the health and safety of the residents in care.

Report serious outbreaks and major accidents

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports.: (2) Occurrences, such as...major accidents which threaten the welfare, safety or health of residents..., shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement was not met as evidence by: Based on LPA’s records review and interviews with the Licensee, the facility failed to notify the Department about R1’s hospitalization on 9/10/25 and R1’s death on 10/31/25, which could pose a potential risk to the health and safety of residents in care.

87463 Reappraisals (i) When there is significant change in condition, ...or once every 12 months, whichever occurs first, the licensee shall arrange an in-person or virtual meeting or conference call to share the reappraisal with the resident, the resident's representative, if applicable, and appropriate facility staff...This requirement was not met as evidence by: Based on LPA’s records review and interviews with the Licensee, the Licensee failed to update R1’s care after they had a significant change of condition, which poses a potential risk to the health and safety of the residents.

Update reappraisal at required intervals

Based on LPA's/back up administrator observation, interview and record review, the licensee did not comply with the section cited above in two out of four residents didn't have current care plans, which poses/posed a potential health, safety or personal rights risk to persons in care.

Obtain and evaluate recent medical assessment

Based on LPA's/back up administrator observation, interview and record review, the licensee did not comply with the section cited above in two out of four rsidents medical assessment were not updated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Obtain baseline medical assessment before resident admission

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in one out of six residents's medical assessments was not current within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.

Document behavioral expression and related causes

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 5 out of 6 residents (R1,R2, R3, R4 & R5) care plan was not updated within the last 12 months, which poses/posed a potential health, safety or personal rights risk to persons in care.