Inspection visit

Health inspectionJuly 9, 2021

VICTORIA HEALTHCARE AND REHABILITATION CENTERCMS #05523711 citations on this visit

11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and facility P&P review, the facility failed to ensure the call lights were kept within the resident's reach for one nonsampled resident (Resident 464) and one of 18 final sampled residents (Resident 40). This failure led to the residents feeling helpless and upset and posed the risk the residents could not use the call light to summon help. Residents Affected - Few Findings: Review of the facility's P&P titled Nursing Clinical, Call Light/Bell revised 05/2007 showed the purpose of this procedure is to provide the resident a means of communication with nursing staff .and staff was to place the call device within a resident's reach. 1. On 7/6/21 at 0811, 0836, and 0841 hours, Resident 464 was observed in bed with the call light button on the floor by Resident 464's bed. Medical record review for Resident 464 was initiated on 7/6/21. Resident 464 was admitted to the facility on [DATE]. Review of Resident 464's H&P examination showed a history of a left shoulder injury status post a fall, chronic hypoxia, and generalized muscle weakness. The H&P examination also showed Resident 464 could make decisions and needs known. On 7/6/21 at 0841 hours, an observation and subsequent interview was conducted with Resident 464. Resident 464 was observed in bed with the call light on the floor next to Resident 464's bed. Resident 464 stated she knew how to use her call light and used the call light when it was near her to ask for assistance. Resident 464 stated her biggest concern was the staff not getting to her quickly if she needed help. Resident 464 stated she was unable to find or reach her call light. Resident 464 became worried, stating she could not reach the call light on the floor. Resident 464 stated she could not get help with the call light on the floor. Resident 464 stated she had recently hurt her shoulder. Resident 464 stated she was worried she would fall out of bed trying to reach the call light on the floor. On 7/6/21 at 0847 hours, CNA 2 was observed entering Resident 464's room. CNA 2 was observed picking the call light up off the floor and pining it to her shirt. On 7/6/21 at 0851 hours, an interview was conducted with CNA 2. CNA 2 stated the purpose of the call light was for the residents to get help if they needed it. CNA 2 verified the call light was on the floor and not accessible to Resident 464 should she need assistance. Cross reference to F880, (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 17 Event ID: 055237 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0558 example #6. Level of Harm - Minimal harm or potential for actual harm 2. On 7/8/21 at 0924 hours, an observation and concurrent interview was conducted with Resident 40. Resident 40 was observed in a wheelchair by her door and her call light was on the wall holder for the bed remote control. Resident 40 stated she needed her call light and could not reach it on the wall. Resident 40 stated a staff member had placed the call light in the holder this morning. Resident 40 stated it made her anxious not to able to get her call light. Resident 40 stated it frightened her when she could not help herself. Resident 40 stated she had to use the bathroom and was worried she would go on herself. Resident 40 stated she was scared she would wet herself. Residents Affected - Few Medical record review for Resident 40 was initiated on 7/8/21. Resident 40 was originally admitted to the facility on [DATE], and readmitted on [DATE]. Review of the H&P examination dated 11/23/21, showed Resident 40 had cognitive impairment and required extensive assistance with her ADL care. On 7/8/21 at 0932 and 1028 hours, an observation and concurrent interview was conducted with CNA 1. CNA 1 verified the call light was not within Resident 40's reach and needed to be accessible to Resident 40. CNA 1 stated the call light needed to be accessible so the resident could get help from the staff when needed. CNA 1 verified the call light was not within Resident 40's reach. CNA 1 verified the above findings. On 7/9/21 at 0740 hours, an interview was conducted with the DON. The DON stated the call light needed to be within reach of the resident. The DON stated the call light should not be on the wall in the remote control holder or on the floor in the resident's room. The DON stated the resident who did not have their call light could fall trying to get the call light. The DON also stated if the resident needed to use the bathroom but could not get help in time, they could have an accident. The DON stated the resident might feel embarrassed if they soiled themselves and it would affect their self-esteem. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 2 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure the privacy for one of 18 final sampled residents (Resident 48). LVN 3 left the privacy curtain open while he injected the medication to Resident 48's abdomen. This failure had the potential to violate the resident's right to privacy by unnecessarily exposing the resident's body during the provision of care. Residents Affected - Few Findings: Medical record review for Resident 48 was initiated 7/6/21. Resident 36 was admitted to the facility 4/29/21. Review of the MDS dated [DATE], showed Resident 48 had severe cognitive impairment. On 7/7/21 at 0855 hours, a medication administration observation was conducted with LVN 3 for Resident 48. Resident 48's bed was by the door. LVN 3 lifted Resident 48's shirt and exposed the middle part of her abdomen and administered the Lovenox (blood thinner medication) injection. Resident 48's privacy curtain was left open. Facility staff were observed passing by in the hallway. On 7/7/21 at 1512 hours, an interview was conducted with LVN 3. LVN 3 acknowledged he did not provide Resident 48 privacy when he left the privacy curtain open during the administration of the Lovenox medication. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 3 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to complete the comprehensive significant change MDS for one of three closed record residents (Resident 64). This had the potential of not providing the appropriate care and services to Residents 64 based on the resident's current status. Residents Affected - Some Findings: Review of the CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1 showed a significant change in status assessment is required to be performed when a terminally ill resident enrolls in a hospice program. The assessment date must be within 14 days from the effective date of the hospice election. Medical record review for Resident 64 was initiated on 7/8/21. Resident 64 was readmitted to the facility on [DATE]. A physician's order dated 5/15/21, showed to admit the resident to hospice care. Review of Resident 64's MDS assessments failed to show a significant change MDS was completed when the resident started hospice services. On 7/8/21 at 0921 hours, an interview and concurrent medical record review was conducted with the MDS Coordinator. The MDS Coordinator verified Resident 64 started hospice services on 5/15/21, and a significant change MDS was not completed. On 7/8/21 at 0930 hours, an interview and concurrent medical record review was conducted with the DON. The DON verified a significant change MDS should have been completed within 14 days of 5/15/21, when the resident entered hospice services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 4 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to accurately complete the MDS assessment for one of three closed record residents (Resident 65). This had the potential to result in the residents being incorrectly coded as discharge to an acute care hospital. Residents Affected - Some Findings: Closed medical record review for Resident 65 was initiated on 7/7/21. Resident 65 was admitted to the facility on [DATE]. Review of the physician's order dated 4/23/21, showed an order to discharge to home on 4/24/21. Review of the MDS dated [DATE], showed the resident had a planned discharge to the acute care hospital. On 7/8/21 at 0939 hours, and interview and concurrent closed medical record review was conducted with the MDS coordinator. The MDS Coordinator verified Resident 65's MDS should show she was discharged to the community. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 5 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and medical record review, the facility failed to ensure the appropriate care and services for the use of the GT for one nonsampled resident (Resident 48). The facility failed to ensure Resident 48's fluid order was provided as prescribed by the physician. This posed the risk for Resident 48 to experience complications. Findings: Medical record review for Resident 48 was initiated on 7/6/21. Resident 48 was readmitted to the facility on [DATE]. Review of the MDS dated [DATE], showed Resident 48 had severe cognitive impairment. Resident 48 was on GT feeding. Review of the Order Summary Sheet dated 7/6/21, showed the enteral feeding order dated 5/25/21, was to flush the GT with 650 ml of water one time a day. On 7/6/21 at 0913, a medication administration observation for Resident 48 was conducted with LVN 2. LVN 2 stated Resident 48 had on order to administer 650 ml of water as a bolus (single administration) daily. LVN 2 stated the volume of fluid was too much for Resident 48 and she decided to divide the 650 ml of the water flush during medication administration. LVN 2 filled up Resident 48's pitcher with 550 ml of water (instead of 650 ml) and administered the water and medications as follows: - 60 ml of water flush to the GT at the beginning of medication administration, - 25 ml of water flush after giving 10 ml of Keppra (antiseizure medication), - 30 ml of water flush after giving 2.5 ml of famotidine (medication for acid reflux), - 35 ml of water flush after giving one tablet of Vitamin D 3 (supplement), - 40 ml of water flush after giving two capsules of probiotic (supplement), and - 60 ml of water flush to the GT at the end of the medication administration. LVN 2 administered a total of 250 ml of water flush when she administered Resident 46's medications. LVN 2 then added the remaining water to Resident 48's GT feeding instead of administering it as part of the 650 ml water flush prescribed by the physician. On 7/6/21 at 1400 hours, an interview and concurrent medical record review was conducted with LVN 2. LVN 2 acknowledged the amount of water she placed in Resident 48's pitcher was only 550 ml instead of the 650 ml of water ordered by the physician. LVN 2 stated she should have administered the remaining water in the pitcher as a bolus flush. LVN 2 acknowledged Resident 48's GT water flushing was not provided as ordered by the physician. On 7/6/21 at 1551 hours, an interview was conducted with the RD. The RD stated Resident 48's fluid (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 6 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0693 order should have been administered as ordered by the physician. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 7 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure accurate accounting and safeguarding of the controlled medications in order to prevent loss, diversion, or accidental exposure. * LVN 3 failed to sign Resident 27's narcotic count sheet for alprazolam (anti-anxiety medication) and Resident 414's narcotic count sheet for hydrocodone (opioid medication for pain) to show when he had administered the medications. Residents 27 and 414's documented remaining counts of tablets on the narcotic count sheets did not reconcile with the actual number of tablets remaining in their medication bubble packs. This posed the risk for loss or diversion of the controlled medications. * The facility failed to ensure the incoming and outgoing licensed nurses assigned to Medication Cart A consistently signed the shift count log. This posed the risk for loss or diversion of the controlled medications. * The facility failed to ensure the emergency kits were replaced after being used. This posed the risk for the emergency medications to not be available when needed. Findings: 1. According to the facility's P&P titled Controlled Medications dated 12/2019, when a controlled medication is administered, the licensed nurse administering the medication immediately enters all of the following information on the accountability record: the date and time of administration, amount administered, and signature of the nurse administering the dose, completed after the medication is actually administered. On 7/6/21 at 1400 hours, a narcotic medication count for Medication Cart A was conducted with LVN 3. LVN 3 verified the following findings: - Resident 27's Narcotic and Hypnotic Record for alprazolam 0.5 mg tablet showed there were 29 tablets remaining. However, Resident 27's medication bubble pack for the alprazolam had only 28 tablets remaining. One tablet of Resident 27's alprazolam was not accounted for. - Resident 414's Narcotic and Hypnotic Record for hydrocodone-APAP 5-325 mg showed there were 40 tablets remaining. However, Resident 414's medication bubble pack for the hydrocodone-APAP had only 38 tablets remaining. Two tablets of Resident 414's hydrocodone-APAP were not accounted for. When asked about the tablet count discrepancies for Residents 27 and 414's controlled medications, LVN 3 stated he forgot to document the controlled medications that he gave to Residents 27 and 414 earlier in the shift. LVN 3 stated he should have signed the Narcotic and Hypnotic Record each time he removed the tablets. On 7/6/21 at 1533 hours, an interview was conducted with the DON. The DON stated the narcotic medications removed from the medication bubble pack had to be accounted for in the narcotic record. 2. According to the facility's P&P titled Controlled Medications dated 12/2019, at each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and is (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 8 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 documented on the audit record. Level of Harm - Minimal harm or potential for actual harm Review of Medication Cart A's Narcotic Check Sheet dated July 2021 showed multiple missing licensed nurses signatures on the following dates: Residents Affected - Few - 7/1/21, for the 11-7 shift, - 7/2/21, for the 7-3 and 3-11 shifts, - 7/3/21, for the 7-3 shift, - 7/4/21, for the 7-3 , 3-11, and 11-7 shifts, and - 7/5/21, for the 3-11 and 11-7 shifts. On 7/6/21 at 1400 hours, an interview and concurrent facility document review was conducted with LVN 3. LVN 3 verified the missing signatures on the Narcotic Check Sheet. LVN 3 stated the narcotic reconciliation count was conducted by the incoming and outgoing nurses on each shift, and both nurses had to sign the Narcotic Check Sheet. LVN 3 stated this was to ensure the narcotic count was accurate. 7/6/21 at 1500 hours, an interview was conducted with DON. The DON stated the licensed nurses had to perform a narcotic count at the end of their shifts with the incoming nurses, and had to sign the narcotic count sheet. The DON verified the findings. 3. According to the facility's P&P titled Medication Ordering and Receiving from Pharmacy: Emergency Pharmacy Service and Emergency Kits dated 1/2/2018, when an emergency or starter dose of a medication is needed, the nurse unlocks the container and breaks the container seal and removes the required medications after informing the pharmacy about the facility's intention to use the emergency kit. The facility informs the pharmacy about replacement of the kit/dose and flags the kit with a color coded lock to indicate the need for replacement of the kit/dose. If exchanging the kits, opened kits are replaced within 72 hours after opening. On 7/6/21 at 0755 hours, an inspection of the medication room was conducted with LVN 1. Emergency Kits A and B were observed each with a red tag. When asked what the red tag meant, LVN 1 stated the red tag meant the emergency kits had been opened and medications had been removed from the kits. Emergency Kit A's IV E Kit Record showed cefepime (intravenous antibiotic) was removed from the kit on 6/29/21. Emergency Kit B's Injectable E Kit Record showed glucagon (medication diabetes) kit was removed from the kit on 6/3/21. LVN 1 verified the medications removed from Emergency Kits A and B should have been replaced. When asked when it had to be replaced, LVN 1 stated she was not sure. On 7/6/21 at 1533 hours, an interview was conducted with the DON. The DON verified the findings. The DON stated the emergency kits had to be replaced immediately after being used. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 9 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and medical record review, the facility failed to ensure the medication error rate was below 5%. The medication error rate was 15.38%. Residents Affected - Few * Resident 48 received partial doses of amiodarone (medications for irregular heart beat), docusate sodium (stool softener), magnesium oxide (supplement), and multivitamin (supplement) when some of the medications were leftover in the medication cups. This had the potential for the resident to experience decreased drug efficacy. Findings: On 7/7/21 at 0855 hours, a medication administration observation for Resident 48 was conducted with LVN 3. LVN 3 prepared the following medications: - one tablet of metoprolol (medication for blood pressure) 25 mg, - one tablet of amiodarone 200 mg, - one tablet of Vitamin C (supplement) 500 mg, - two tablets of docusate sodium 100 mg, - one table of multivitamin, - 5 ml of levetiracetam (antiseizure medication) 100 mg, - Lovenox (blood thinner) 40 mg injection, and - one coated tablet of magnesium oxide 400 mg. LVN 3 crushed each of the medications separately including the magnesium oxide coated tablet. LVN 3 added water in each of the medication cups. A portion of Resident 48's crushed magnesium oxide spilled on top of the medication cart and medication tray. LVN 3 administered Resident 48's medications via the GT. A significant amount of leftover medications were observed in the medication cups containing docusate sodium, magnesium oxide, amiodarone, and multivitamin. LVN 3 acknowledged the leftover medications were the magnesium oxide, amiodarone, and multivitamins. LVN 3 acknowledged Resident 48's magnesium oxide was a coated preparation and should not have been crushed. LVN 3 acknowledged a portion of Resident 48's crushed magnesium oxide medication was spilled on the medication cart and tray. LVN 3 acknowledged Resident 48 did not receive the full doses of the docusate sodium, magnesium oxide, amiodarone, and multivitamin as ordered by the physician. On 7/7/21 at 1043 hours, an observation of the medication cups containing the residual medications was conducted with the DON. The DON acknowledged the significant amount of leftover medication remaining in the cups that were not administered to Resident 48. The DON stated Resident 48's medications should have been diluted properly to ensure the full doses were administered. The DON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 10 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Resident 48's magnesium oxide had to be clarified with the physician since it was a coated medication and should not have been crushed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 11 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation and interview, the facility failed to ensure the medications were stored and labeled properly. An undated vial of Tubersol (Tuberculin Purified Protein Derivative used in a skin test to aid in diagnosis of tuberculosis infection), an unlabeled cup of a white powdery substance, an unlabeled inhaler, and an unlabeled tube of diclofenac (pain medication) gel were observed in Medication Cart A. This had the potential for unsafe administration of medications. Findings: On 7/6/21 at 1400 hours, an inspection of Medication Cart A was conducted with LVN 3. LVN 3 verified the following findings: - an opened and undated vial of Tubersol Purified Protein Derivative, - a used, unlabeled, and undated Trelegy (medication for asthma) metered dose inhaler (MDI), - a unlabeled, undated, cup containing an unknown white powdery substance, - an opened, unlabeled, and undated 100 grams tube of diclofenac sodium topical gel 1%. LVN 3 stated he did know when the Tubersol vial was opened. LVN 3 stated the Tubersol vial had to be refrigerated and was good for only 30 days. LVN 3 verified the Trelegy MDI and diclofenac gel were not labeled with the resident's name, opened date, and instructions. LVN 3 stated he did not know what the white powdery substance was. On 7/7/21 at 1500 hours, an interview was conducted with the DON. The DON was made aware of the findings. The DON stated the medications had to be labeled and dated with the opened date. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 12 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the medical records were complete for three of 18 final sampled residents (Residents 3, 59 and 564). * The psychiatric consultant's progress notes for 1/4 and 6/25/21, were not in the Resident 59's medical record. * The psychiatric consultant's progress notes for 1/4/21, were not in the Resident 3's medical record. * Resident 564's follow-up urology appointment progress note from 3/24/21, was not in the resident's medical record. These failures had the potential for the residents' medical statuses and plans to not be easily accessible to the multidisciplinary team for continuity of care. Findings: 1. Medical record review for Resident 59 was initiated on 7/6/21. Resident 59 was readmitted to the facility on [DATE]. Review of Resident 59's Order Summary Report dated 7/9/21, showed a physician order from 9/13/18, for psychiatric/psychogeriatric consult and follow-up as indicated. The summary also showed a physician order dated 6/25/21, for Risperdal (an antipsychotic medication) 0.5 mg two times a day for behavioral and psychological symptoms of dementia. The psychiatrist's progress note dated 5/28/21, showed a behavioral health treatment review for the resident's psychotropic medications. No other psychiatric consultant progress notes were available in Resident 59's medical record to show the resident's treatment plan and progress. On 7/8/21 at 1218 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 stated Resident 59 has been followed by the psychiatrist at the facility for awhile now. LVN 1 was unable to locate any other psychiatric progress notes and show additional dates when Resident 59 was seen by the psychiatrist. On 7/8/21 at 1514 hours, an interview and concurrent record review was conducted with the DON. The DON stated she had requested the records from the psychiatric consultant group and a progress note dated 1/4/21, was emailed to the DON that day. On 7/8/21 at 1604 hours, an interview and concurrent record review was conducted with the Medical Records Director. The Medical Records Director stated they were able to locate one psychiatric progress note in the resident's thinned records stored in the medical records department. The Medical Records Director provided a copy of progress note dated 12/9/19. On 7/9/21 at 1023 hours, the DON stated the psychiatric consultant group emailed her a progress note dated 6/25/21. When asked if the progress note was sent after the facility requested the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 13 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few consultant's progress notes, the DON replied yes. The DON stated there was no process for obtaining the consultant reports, simply when they received them, they printed them and placed in the resident's medical record. 2. Medical record review for Resident 3 was initiated on 7/6/21. Resident 3 was readmitted to the facility on [DATE]. Review of Resident 3's Order Summary Report dated 7/9/21, showed a physician order from 1/17/19, for psychiatric/psychogeriatric consult and follow-up as indicated. Review of the Weekly Skilled Review progress note dated 10/9/20, showed Resident 3 had increased tremors and episodes of depression and to refer the resident to the psychiatry for crying spells. On 7/9/21 at 0806 hours, an interview and concurrent record review was conducted with LVN 1. LVN 1 stated Resident 3 had been followed by the psychiatric consultant. When asked for the frequency of the visits, LVN 1 stated the consultant visited every Friday, but did not know which residents were seen by the consultant each week. LVN 1 verified there was a psychiatric progress note in the resident's record dated 8/13/20, and did not know if the Resident 3 had a consult since. On 7/9/21, LVN 1 verified they were unable to locate any other psychiatric progress notes for Resident 3. On 7/9/21 at 0840 hours, and interview and concurrent record review was conducted with the DON. The DON verified the Weekly Skilled Review progress note dated 10/9/20, showed to refer the Resident 3 to the psychiatry for crying spells. The DON was unable to show when the consult was completed. On 7/9/21 at 0909 hours, a follow-up interview and record review was conducted with LVN 1. LVN 1 stated the facility had just received a psychiatric progress note from the psychiatric group's offices dated 1/4/21. 3. Medical record review for Resident 564 was initiated on 7/6/21. Resident 564 was admitted to the facility on [DATE]. A physician's order dated 3/19/21, showed a follow-up appointment was scheduled on 3/24/21. Review of the nursing progress note dated 3/24/21 at 1055 hours, showed Resident 564's and Family Member 1 returned form a urology appointment with the new orders for antibiotics. On 7/7/21 at 1534 hours, an interview was conducted with Family Member 1. Family Member 1 stated she went with Resident 564 to the urology appointment on 3/24/21. Family Member 1 stated the urologist gave her a packet and she gave to a facility staff after the appointment. On 7/8/21 at 1433 hours, an interview and concurrent record review was conducted with LVN 2. LVN 2 stated Resident 564's went out for a urology appointment on 3/24/21, with a family member, and the new orders were obtained after the appointment. LVN 2 was unable to locate Resident 564's urology consult progress notes to show what occurred at the appointment, the residents status and plan of care as well as order recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 14 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Medical record review for Resident 5 was initiated on 7/6/21. Resident 5 was admitted to the facility on [DATE], and readmitted on [DATE]. Residents Affected - Few On 7/6/21 at 0730 hours, Resident 5's urinary drainage bag and tubing were observed touching the floor. On 7/6/21 at 1227 hours, CNA 3 was asked to come to Resident 5's room. Resident 5's urinary drainage bag and tubing were observed touching the floor. CNA 3 verified the findings. On 7/8/21 at 1630 hours, an interview was conducted with the DON. The DON stated the urinary drainage bag and tubing should be kept off of the floor to prevent the infections. 4. On 7/6/21 at 0913 hours, a medication administration observation for Resident 46 was conducted with LVN 2. LVN 2 took a stack of medication cups with her bare hands and touched the rim and inside of the cups. LVN 2 placed the medication in each cup. LVN 2 took plastic pill crushing bags and opened them by inserting her ungloved finger inside the bags. LVN 2 crushed each medication individually using the plastic pill crushing bags she had touched the inside of with her bare finger. LVN 2 administered the medications to Resident 46 via the GT. On 7/6/21 at 1413 hours, an interview was conducted with LVN 2. LVN 2 acknowledged she touched the inside of the medication cups and plastic pill crushing bags used to crush Resident 46's medications. LVN 2 stated she should not have used her bare fingers to open up the bags and should have only touched the outside of the medication cups to prevent contamination. 5. On 7/7/21 at 0855 hours, a medication administration observation for Resident 48 was conducted with LVN 3. LVN 3 was observed disinfecting the blood pressure apparatus and stethoscope he used on Resident 48. LVN 3 took multiple medication cups and had his finger inside the cups. LVN 3 took plastic pill crushing bags and opened them by inserting his bare finger inside the bags. LVN 3 crushed Resident 48's medications individually in the plastic pill crushing bags. LVN 3 administered Resident 48's medications via the GT. On 7/7/21 at 1512 hours, an interview was conducted with LVN 3. LVN 3 acknowledged he touched the insides of the medication cups and bags that he used when preparing Resident 48's medications. Based on observation, interview, medical record review, and facility P&P review, the facility failed to implement the infection control practices designed to help prevent the development and transmission of diseases and infections for four of 18 final sampled residents and one nonsampled resident (Residents 5, 46, 48, 414, and 464). * The facility failed to ensure the staff maintained sanitary conditions for the indwelling urinary catheters of Residents 5, 48, and 414. * The licensed staff failed to ensure proper handling of equipment used during the medication administration for Residents 46 and 48. * CNA 2 failed to ensure the call light was cleaned after picking it up off the floor and handing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 15 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 it to the Resident 464. Level of Harm - Minimal harm or potential for actual harm These failures had the potential for cross-contamination and spread of infectious organisms in the facility. Findings: Residents Affected - Few 1. On 7/6/21 at 1538 hours, Resident 414 was observed sitting in a wheelchair with the indwelling urinary catheter tubing touching the floor. On 7/7/21 at 1615 hours, Resident 414 was observed lying in bed with the indwelling urinary catheter tubing touching the floor. On 7/7/21 at 1643 hours, an observation of Resident 414 was conducted with LVN 4. LVN 4 verified Resident 414's indwelling urinary catheter tubing should not be touching the floor, and stated the tubing touching the floor could increase the risk of infection to the resident. 2. On 7/6/21 at 0817 hours, 7/7/21 at 1000 hours, and 7/8/21 at 0715 hours, Resident 48 was observed lying in bed with the indwelling urinary catheter attached to a drainage bag. The drainage bag was covered with a cloth covering. The indwelling urinary catheter tubing was clipped to the lower part of the bed and the cloth covering surrounding the urinary drainage bag was touching the floor. On 7/8/21 at 0747 hours, an observation of Resident 48 was conducted with LVN 3. LVN 3 verified the cloth covering the catheter drainage bag was touching the floor. LVN 3 stated the catheter drainage bag should not touch the floor to help prevent the risk of infection to the resident. On 7/8/21 at 1611 hours, an interview was conducted with the DON. The DON stated to help prevent infections, the indwelling urinary catheter tubing and urinary drainage bag covers should be kept off of the floor at all times.6. On 7/6/21 at 0811, 0836, and 0841 hours, Resident 464 was observed in bed with the call light on the floor by Resident 464's bed. On 7/6/21 at 0847 hours, CNA 2 was observed entering Resident 464's room. CNA 2 was observed picking the call light up from the floor then handing the call light to Resident 464 and pinning it to the resident's shirt. CNA 2 did not clean or disinfect the call light after picking it up from the floor. On 7/6/21 at 0851 hours, an interview was conducted with CNA 2. CNA 2 verified the call light was on the floor and not by Resident 464. CNA 2 verified she did not clean or disinfect the call light after picking it up from the floor and before attaching the call light clip to Resident 464's clothing. CNA 2 acknowledged the call light needed to be cleaned since the floor was dirty. CNA 2 verified she should have cleaned the call light before clipping it to Resident 464's shirt and handing her the call light. Cross reference to F588, example #1. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 16 of 17 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055237 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/09/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Victoria Healthcare and Rehabilitation Center 340 Victoria Street Costa Mesa, CA 92627 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and facility document review, the facility failed to establish an infection control program designed to provide a safe and sanitary environment. Residents Affected - Few * The facility failed to ensure the assessment of residents' signs and symptoms were reviewed and documented for appropriateness of antibiotic use in the Infection Control Surveillance logs for the months of March, April and May 2021. This failure posed the risk of inappropriate antibiotic usage and inaccuracy of data. Findings: According to the CDC, unnecessary antibiotic use promotes development of antibiotic-resistant bacteria. Every time a person takes antibiotics, sensitive bacteria are killed, but resistant germs may be left to grow and multiply. Repeated and improper use of antibiotics is the primary cause of the increase in drug-resistant bacteria. Review of the facility's P&P titled Antimicrobial Stewardship Program revised 09/17 showed the facility may consider antibiotic time out practices. These practices include improving the evaluation and communication of clinical signs and symptoms when a resident is first suspected of having an infection, optimizing the use of diagnostic testing and implementing an antibiotic review process, also known as an antibiotic time-out for all antibiotics prescribed in the facility. Antibiotic reviews provide clinicians with an opportunity to reassess the ongoing need for and choice of an antibiotic when the clinical picture is clearer and more information available. Review of the Infection Control Surveillance Logs for the months of March to May 2021 showed the following: - For March 2021, two HAI cases met McGeer's criteria and 12 HAI cases did not meet McGeer's criteria. - For April 2021,one HAI cases met McGeer's criteria and four HAI cases did not meet McGeer's criteria. - For May 2021, two HAI cases met McGeer's criteria and nine HAI cases did not meet McGeer's criteria. Further review of the Infection Control Surveillance Logs for March, April, and May 2021 showed a list of residents who were on antibiotic. However, the Infection Prevention and Control Surveillance logs did not show any documentation of the residents' signs and symptoms of HAI which met or did not meet the McGeer's criteria during those months. On 7/8/21 at 0754 hours, an interview and concurrent review of the facility's infection control program was conducted with the Infection Preventionist. The Infection Preventionist verified the Infection Control Surveillance Logs for March, April, and May 2021 were incomplete. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055237 If continuation sheet Page 17 of 17

Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.

Citations

11 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0583GeneralS&S Dpotential for harm
F583 - Privacy and Confidentiality
Keep residents' personal and medical records private and confidential.
0637GeneralS&S Bno actual harm
F637 - Within 14 days after the facility determines, or should have determined,
Assess the resident when there is a significant change in condition
0641GeneralS&S Bno actual harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0693GeneralS&S Dpotential for harm
F693 - Assisted nutrition and hydration
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0761GeneralS&S Dpotential for harm
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
0842GeneralS&S Dpotential for harm
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
0880GeneralS&S Dpotential for harm
F880 - Infection Control
Provide and implement an infection prevention and control program.
0881GeneralS&S Dpotential for harm
F881 - Infection prevention and control program
Implement a program that monitors antibiotic use.
0759GeneralS&S Dpotential for harm
F759 - Medication Errors
Ensure medication error rates are not 5 percent or greater.

FAQ · About this visit

Common questions about this visit

What happened during the July 9, 2021 survey of VICTORIA HEALTHCARE AND REHABILITATION CENTER?

This was a inspection survey of VICTORIA HEALTHCARE AND REHABILITATION CENTER on July 9, 2021. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at VICTORIA HEALTHCARE AND REHABILITATION CENTER on July 9, 2021?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Reasonably accommodate the needs and preferences of each resident."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·July 9, 2021