Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Victoria Care Center during CMS and state inspections, most recent first.
A resident with symptoms of a UTI did not receive the first dose of a newly ordered antibiotic, Cipro, in a timely manner. The nurse waited for pharmacy delivery instead of using the Emergency Medication Kit, and did not adjust the administration time, resulting in a delay of treatment.
A resident with a history of DVT and PE missed six doses of Lovenox due to unavailability, and staff did not notify the physician as required by facility policy. Interviews confirmed that both pharmacy and physician notification were expected but not completed.
The facility failed to implement care plan interventions for several residents, including not providing necessary equipment for skin maintenance, not completing medication administration, and not documenting IV hydration. Residents were not repositioned regularly, and one resident did not receive a snack during dialysis. These deficiencies were confirmed by staff and led to unmet resident needs.
The facility failed to maintain resident dignity and timely response to call lights, affecting three residents. A resident's confidential medical information was publicly displayed, violating their privacy. Two residents experienced significant delays in call light responses, leading to feelings of embarrassment and frustration. The facility's policy on call light response times was not adhered to, with observed delays far exceeding the expected 10-minute response time.
A facility failed to ensure consistent documentation of a resident's POLST across paper and electronic records. The paper POLST indicated selective treatment preferences, while the electronic version suggested full treatment, including intubation. Licensed nurses confirmed the discrepancies, which could lead to the resident's end-of-life wishes not being honored.
A resident was not involved in the review and revision of their care plan during an IDT meeting, contrary to facility policy. Staff interviews revealed that the resident was not invited to the meeting, and changes to the care plan were not reviewed with them afterward. This resulted in the resident not participating in deciding their treatment options.
A facility failed to maintain accurate medical records for two residents. One resident was relocated without proper notification or consent, violating facility policy. Another resident's depression and mood were not monitored as ordered, with missing documentation on specific shifts. The DON acknowledged these deficiencies, which could impact care planning and resident rights.
The facility failed to adhere to its Infection Prevention and Control Program, with staff not following Enhanced Barrier Precautions for a resident, improper hand hygiene during feeding, and inadequate labeling and storage of medical equipment. Additionally, a nurse did not change gloves after picking up a dropped item, and another did not perform hand hygiene during wound care, all contrary to facility policies.
The facility failed to ensure a functional environment by not providing pull cords for night lights in several resident rooms, as confirmed by maintenance staff. This deficiency denied residents the use of night lights, potentially increasing fall risk.
A resident experienced an unwitnessed fall and was found confused and forgetful. The facility failed to promptly notify the resident's representative, delaying their involvement in care decisions. The representative was informed hours later, after the physician ordered the resident to be sent to the ER due to anticoagulant therapy, which was deemed a life-threatening situation.
A resident experienced an unwitnessed fall, and the facility failed to ensure a prompt physician response, resulting in a delayed transfer to the ER. The facility's policy requires timely physician advice and treatment, but the physician took three hours to respond to the nursing staff's call. The Director of Nursing confirmed that this delay did not meet the facility's expectations for prompt communication.
A resident transferred to a skilled nursing facility for post-knee replacement care did not receive a scheduled dose of the prescribed antibiotic, sulfamethoxazole-trimethoprim (Bactrim DS), on the day of admission. The Director of Nursing confirmed the oversight, which could have impacted the effectiveness of the treatment.
A resident was discharged without receiving the necessary antibiotic medication for a knee surgical incision infection. The facility's policy required contacting the prescriber if medication delivery was delayed, but the pharmacy did not deliver the medication in time. The Director of Nursing confirmed the medication was unavailable at discharge, acknowledging the pharmacy's failure to meet the resident's needs.
The facility failed to include necessary interventions in the care plans of two residents with pressure ulcers. The care plans lacked measures for offloading heels and did not specify a frequency for turning and repositioning. Additionally, one resident's care plan did not include a specific fluid intake amount despite a physician's order for fluid restriction. These deficiencies were confirmed by the ADON during a review.
A facility failed to accurately document a resident's skin assessment, resulting in an inaccurate care history. The resident, admitted with congestive heart failure, had conflicting records regarding a coccyx pressure ulcer. The Initial Admission Record did not note the ulcer, while subsequent evaluations provided inconsistent onset dates. The Assistant Director of Nursing confirmed an error in the documentation, violating the facility's policy for accurate and chronological record-keeping.
A resident reported being physically abused by a CNA, but the facility delayed reporting the allegation to CDPH beyond the required 24-hour timeframe. The incident was initially reported internally to the Charge Nurse, Nurse Practitioner, DON, and Administrator, but external reporting was not timely, contrary to the facility's policy.
A resident requiring a Kosher diet was not provided with appropriate meals, as the facility failed to include this dietary need in the care plan. Despite informing the RD and DS of his dietary preferences, the resident was served non-Kosher foods. The care plan was only revised to include a Kosher diet after the resident's discharge, contrary to the facility's policy for comprehensive care planning.
A resident with a history of bipolar and anxiety disorders became agitated and wanted to leave the facility after a CNA was rude and used foul language. The incident was confirmed by the DON and documented in the resident's progress notes, highlighting a failure to uphold the facility's policy on Residents' Rights.
Delay in Administration of Antibiotic for UTI
Penalty
Summary
A deficiency occurred when a resident exhibiting signs of a urinary tract infection (foul smelling urine) did not receive the first dose of a newly ordered antibiotic, Cipro, within a reasonable timeframe. The physician's order for Cipro was placed in the late afternoon, with instructions for same-day delivery from the pharmacy. However, the medication was not administered as scheduled, and the nurse did not adjust the administration time for the first dose. The Medication Administration Record showed that the initial dose was not given at the intended time, and there was no documentation of an adjusted administration time. The Assistant Director of Nursing confirmed that the nurse did not utilize the Emergency Medication Kit to obtain the Cipro, instead waiting for the pharmacy delivery. Facility policy states that if a medication is not immediately available and is needed urgently, it should be obtained from the Emergency Medication Supply. The failure to follow this policy resulted in a delay in administering the antibiotic to the resident.
Failure to Administer Anticoagulant as Ordered and Notify Physician
Penalty
Summary
The facility failed to follow physician's orders for the administration of Lovenox (Enoxaparin Sodium Injection) for a resident who was admitted with a post-operative diagnosis of deep vein thrombosis (DVT) and pulmonary embolism (PE). The hospital discharge summary included orders for Lovenox 100 mg to be administered subcutaneously every 12 hours. Review of the electronic medication administration record and physician orders revealed that the resident missed six doses of Lovenox over a four-day period, and there was no documentation that the physician was notified about the unavailability or delay of the medication. Interviews with the nurse supervisor and the director of nursing confirmed that nursing staff are expected to notify the pharmacy and the physician if a medication is unavailable, and acknowledged that the physician should have been contacted. Facility policy also requires the prescriber to be contacted when medication delivery is delayed or unavailable.
Failure to Implement Care Plan Interventions
Penalty
Summary
The facility failed to implement care plan interventions for several residents, leading to unmet needs and potential harm. Resident 61 did not receive a foot cradle and alternate pressure mattress as ordered for skin maintenance. Resident 123's care plan interventions, including oxygen therapy and monitoring for insomnia and pain, were not completed on multiple occasions. Similarly, Resident 138's interventions, such as being up to a chair for meals and monitoring for signs of bleeding, were not implemented as required. Resident 682, who was transferred to the facility after a hip fracture repair, did not have proper documentation for IV hydration, which was crucial for managing elevated BUN levels. The lack of documentation and administration of IV fluids as per the care plan was confirmed by the nursing staff. Additionally, Resident 5, who has multiple sclerosis, reported not being regularly turned and repositioned, which was a necessary intervention to prevent further decline in physical mobility and skin breakdown. Furthermore, Resident 36, who requires dialysis, was not provided with a snack during treatment as ordered, leading to potential nutritional deficiencies. Resident 121, who needed pillows to offload pressure from heels, did not have this intervention documented or implemented, despite a physician's order. The facility's failure to adhere to care plans and document interventions as required was acknowledged by the Director of Nursing and other staff members during interviews.
Failure to Maintain Resident Dignity and Timely Response to Call Lights
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by several incidents involving three residents. Resident 110's confidential medical information was publicly displayed in their room, violating their right to privacy and dignity. An orange Swallow Guide containing specific treatment details was posted at the head of their bed, which should have been covered to protect their confidentiality. Two residents, Resident 240 and Resident 66, experienced significant delays in call light responses, leading to feelings of embarrassment, frustration, and anger. Resident 240 reported waiting up to an hour for staff to respond, resulting in instances where they had to void in their bed. The Nurse Call Activity Report (NCAR) for Resident 240 showed multiple instances of prolonged call durations, some exceeding 30 minutes. Similarly, Resident 66 expressed dissatisfaction with the night shift's response times, stating they often waited an hour or more for assistance. This delay caused Resident 66 to feel angry, frustrated, and embarrassed, as they were left in pain, hungry, and thirsty. The NCAR for Resident 66 also indicated numerous instances of extended call durations, with some exceeding 40 minutes. The facility's policy on call light response times was not adhered to, as the Director of Nursing acknowledged that a reasonable expectation for response time was 10 minutes, and the observed delays were unacceptable.
Inconsistent POLST Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident had the most current Physician Orders for Life-Sustaining Treatment (POLST) documented consistently across both paper and electronic records. The POLST is a critical document that outlines a resident's treatment preferences in the event of a medical emergency. In this case, discrepancies were found between the paper POLST and the electronic health record (eHR) for the resident. The paper POLST indicated a preference for selective treatment, avoiding burdensome measures, and not intubating, while the electronic POLST indicated a trial period of full treatment, including intubation and mechanical ventilation. During interviews and record reviews, it was confirmed by licensed nurses that the paper and electronic POLST documents did not match, which they acknowledged should not be the case. This inconsistency in documentation had the potential to result in the resident's end-of-life wishes not being honored, as emergency personnel might follow incorrect or outdated instructions during a medical emergency.
Resident Excluded from Care Plan Meeting
Penalty
Summary
The facility failed to ensure that Resident 106 was involved in the review and revision of their care plan during the interdisciplinary team (IDT) meeting. The facility's policy and procedure indicated that residents, along with their families or responsible parties, should participate in the development of the care plan. However, Resident 106 was not invited to the IDT meeting, and the changes made to the care plan were not reviewed with them afterward. This lack of involvement resulted in Resident 106 not being given the opportunity to participate in deciding their treatment options. Interviews with facility staff, including a social services designee (SSD), a minimum data set nurse assessment coordinator (MDS2), and the Director of Nursing (DON), confirmed that Resident 106 was not present at the care plan meeting. The SSD acknowledged speaking with Resident 106 before the meeting but did not review the care plan changes with them afterward. MDS2 admitted that residents are never present at these meetings and that the revisions are not reviewed with them, which was acknowledged as a deviation from the expected practice. The DON confirmed that all residents should be present at care plan meetings if they are able to attend, highlighting a systemic issue in the facility's process.
Deficiencies in Documentation and Resident Notification
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, leading to deficiencies in care and resident rights. For one resident, the facility did not maintain a complete, accurately documented, and systematically organized room transfer form during their relocation. The resident was moved without prior notification or consent, as required by the facility's policy. The Director of Nursing (DON) confirmed that the resident was verbally informed, but no written notification or consent was obtained, and the form used was incorrectly titled 'STATUS CHANGE' instead of 'Notification of Room or Roommate Change.' This discrepancy in documentation and lack of proper notification violated the facility's policy and the resident's rights. For another resident, the facility failed to monitor the resident's depression and mood as ordered by the physician. The resident was on medication for mood disorders and depression, with specific orders to monitor episodes of depression and mood disorder using hashmarks every shift. However, there was no documentation of monitoring on two specific PM shifts. The DON acknowledged the lack of documentation, which was contrary to the facility's policy requiring a complete account of the resident's care and treatment in an accurate and chronological order. This failure to document monitoring could impact the resident's care planning and the provision of appropriate care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to its Infection Prevention and Control Program (IPCP) in several instances. Staff did not follow Enhanced Barrier Precautions (EBP) for a resident who required such measures. During an observation, an occupational therapist and a physical therapist provided direct care to the resident without wearing gowns, despite signage indicating the need for EBP. The facility's policy required the use of gowns and gloves during high-contact activities to prevent the spread of multidrug-resistant organisms. In another instance, a certified nurse assistant (CNA) was observed feeding two residents simultaneously, using the same hand and utensil without proper hand hygiene between feedings. The facility's policy allowed one staff member to feed two residents but required adherence to infection control guidelines to prevent cross-contamination. The CNA did not follow the hand hygiene policy, which mandates handwashing before and after direct contact with residents and before and after assisting with meals. Additionally, the facility failed to label and properly store oxygen and nebulizer equipment for two residents, and a medication nurse did not change gloves after picking up a dropped item before administering a patch to a resident. Furthermore, a treatment nurse did not perform hand hygiene between glove changes during wound care for another resident. These actions were contrary to the facility's policies, which required weekly changes and labeling of equipment and emphasized the importance of handwashing in infection control.
Missing Night Light Pull Cords in Resident Rooms
Penalty
Summary
The facility failed to provide a functional and comfortable environment for residents by not ensuring the availability of pull cords for overhead night lights in several resident rooms. During an initial tour observation, it was noted that rooms 109A, 110A, 113A, 113B, 114A, 114B, 115A, 116A, 116B, 118A, 118B, 119B, 120A, 121A, 124A, and 125A were missing night light pull cords. This deficiency was confirmed during an interview with the Director of Maintenance and the Assistant Maintenance, who acknowledged the absence of pull cords in the identified rooms. The lack of pull cords denied residents the use of night lights, potentially increasing the risk of falls during nighttime hours.
Delayed Notification of Resident Fall
Penalty
Summary
The facility failed to promptly notify the resident representative of a fall experienced by a resident, which was a deviation from the facility's policy and procedure on Fall Management System. The policy, dated January 2022, required that the resident representative be informed of any fall and the resident's status. On January 23, 2025, at 3:18 a.m., a progress note documented that the resident had an unwitnessed fall, was confused, and forgetful. However, the resident's representative was not informed of the incident until 6:08 a.m., resulting in a delay in their involvement in decision-making regarding the resident's care. The facility's policy on Change of Condition Reporting/Documentation, dated 2023, also required that the responsible party be notified of any change in the resident's condition. During an interview and record review, the Director of Nursing acknowledged that the resident's representative should have been notified at the time of the fall. The delay in notification meant that the resident's representative was not immediately involved in critical decisions, such as the physician's order to send the resident to the emergency room due to anticoagulant therapy, which was considered a life-threatening situation by the representative.
Delayed Physician Response After Resident Fall
Penalty
Summary
The facility failed to ensure prompt physician response following a resident's fall, leading to a delayed transfer to the emergency room. According to the facility's policy and procedure on physician services, physicians are expected to provide advice, treatment, and determine the appropriate level of care needed for each resident. On January 23, 2025, at 3:18 a.m., a progress note indicated that a resident had an unwitnessed fall, and the nursing staff communicated with the physician, awaiting a response. However, the physician did not respond until 6:08 a.m., approximately three hours later, at which point the order was given to send the resident to the hospital for further evaluation and treatment. During an interview and record review with the Director of Nursing, it was confirmed that the physician's delayed response did not meet the facility's expectations for prompt communication.
Antibiotic Administration Failure Post-Transfer
Penalty
Summary
The facility failed to ensure that a resident received their prescribed antibiotic treatment without interruption following a transfer from an acute care facility to the skilled nursing facility. The resident, a female admitted for aftercare following knee replacement surgery, was prescribed sulfamethoxazole-trimethoprim (Bactrim DS) to be taken twice daily for five days. The discharge instructions from the hospital indicated that the last dose was administered at 10 AM on the day of transfer. Upon review of the resident's records, it was found that the second dose of the antibiotic was not administered as scheduled at 5 PM on the day of admission to the nursing facility. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that the dose should have been given. The failure to administer the antibiotic as prescribed had the potential to reduce the effectiveness of the treatment and/or prolong the resident's recovery process.
Failure to Provide Antibiotic Medication on Discharge
Penalty
Summary
The facility failed to ensure that a resident was provided with the necessary antibiotic medication upon discharge. The facility's policy and procedure required contacting the prescriber if there was a delay in medication delivery. The resident had an order for Bactrim DS to treat a right knee surgical incision infection. On the day of discharge, the facility sent a fax to the pharmacy requesting the medication, but it was not delivered in time. The Medication Administration Record indicated that the resident was discharged to home without the medication. A progress note documented concerns about how the resident would obtain the medication since it had not been delivered. The Director of Nursing confirmed that the medication was not available to send home with the resident, acknowledging that the pharmacy did not meet the resident's medication needs.
Deficiencies in Care Plans for Pressure Ulcer Management
Penalty
Summary
The facility failed to ensure that the care plans for two residents with pressure ulcers included necessary interventions. For both residents, the care plans did not specify the offloading of heels from pressure surfaces, which is a critical measure to prevent the worsening of pressure ulcers. Additionally, the care plans lacked a defined frequency for turning and repositioning the residents, which is essential for pressure ulcer prevention. These omissions were identified during a review of the care plans and confirmed by the Assistant Director of Nursing, who acknowledged that the interventions should have been included. Furthermore, the care plan for one of the residents did not specify the amount of fluid intake, despite a physician's order for a fluid restriction. The care plan merely encouraged fluid intake without detailing the specific amount, which could lead to fluid overload. This oversight was also confirmed during the review with the Assistant Director of Nursing, who noted that the intervention was not resident-specific as it lacked the necessary details regarding fluid intake.
Inaccurate Documentation of Resident's Skin Assessment
Penalty
Summary
The facility failed to ensure accurate documentation of a skin assessment for a resident, leading to an inaccurate resident care history. The resident, who was admitted with a primary diagnosis of congestive heart failure, had discrepancies in the documentation of a pressure ulcer on the coccyx. The Initial Admission Record (IAR) did not indicate the presence of a coccyx pressure ulcer upon admission, while the Change in Condition Evaluation (CiCE) noted the ulcer started on a later date. However, the Skin Pressure Ulcer Weekly (SPUW) report inaccurately documented the ulcer as present on admission with an onset date prior to the CiCE's noted start date. During a review with the Assistant Director of Nursing (ADON), it was confirmed that the SPUW contained an error regarding the onset date of the pressure ulcer. The facility's policy on documentation and charting requires a complete and accurate account of the resident's care in a chronological manner, which was not adhered to in this instance. This discrepancy in documentation highlights a failure in maintaining accurate medical records for the resident.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) in a timely manner for one of the sampled residents. On July 17, 2024, at 6:35 p.m., a resident reported to the Charge Nurse that her assigned Certified Nursing Assistant (CNA) had physically abused her by pinching and pulling her hair. The Charge Nurse immediately informed the Nurse Practitioner, Director of Nursing (DON), and Administrator about the allegation. However, the facility did not report the incident to CDPH until July 19, 2024, at 3:30 p.m., which was beyond the required 24-hour reporting timeframe. The facility's policy and procedure on abuse prevention and prohibition mandates that such allegations be reported to the appropriate state or federal agencies within the applicable timeframes. The DON acknowledged the delay in reporting during an interview, admitting that the report should have been made within 24 hours.
Failure to Implement Kosher Diet in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who required a Kosher diet, resulting in the resident receiving non-Kosher foods. The resident, who was discharged from the facility, reported that despite informing the Registered Dietician and Dietary Supervisor of his dietary needs upon admission, he was served ham and cheese sandwiches, which are not Kosher. The resident's dietary assessment, completed by the RD, indicated a preference for a Kosher diet and listed specific food dislikes, including ham and pork. The Nutritional Care Plan for the resident, initiated on the same date as the dietary assessment, identified an increased risk for malnutrition but did not include specific interventions for a Kosher diet until after the resident's discharge. The Director of Nursing acknowledged that the care plan was revised to include the Kosher diet only after the resident had left the facility. The facility's policy requires the interdisciplinary team, including the Dietary Supervisor/Dietician, to develop a comprehensive, person-centered care plan based on the resident's needs, which was not adhered to in this case.
Resident Rights Violation Due to CNA's Rude Behavior
Penalty
Summary
The facility failed to protect the rights of a resident when a Certified Nursing Assistant (CNA) was rude to them, resulting in the resident becoming agitated and wanting to leave the facility. The resident, who was admitted for rehabilitation therapy after gallbladder surgery and has a history of bipolar disorder and anxiety disorder, experienced emotional distress due to an argument with the CNA. During an interview, the Director of Nursing (DON) confirmed that the CNA used foul language and made inappropriate comments to the resident. The Nursing Progress Note indicated the resident was restless and emotionally distressed following the incident, and the Psychiatric Progress Note confirmed the resident's account of the CNA's rude behavior. The facility's policy on Residents' Rights emphasizes the right to be treated with respect and dignity, which was not upheld in this instance.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Ventura
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Coastal View Healthcare Center | 1.3 mi | ★★★★★ | 11 | 0 |
| Ventura Post Acute | 1.7 mi | ★★★★★ | 0 | 0 |
| Oxnard Manor Healthcare Center | 3.2 mi | ★★★★★ | 13 | 0 |
| Glenwood Care Center | 3.8 mi | ★★★★★ | 1 | 0 |
| Shoreline Care Center | 6.1 mi | ★★★★★ | 17 | 0 |
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