Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A resident's administration of hydrocodone/APAP 5-325 mg was not accurately documented, with one instance where the MAR showed two tablets given when only one was removed, and another instance where a tablet was removed but not documented as administered. The DON confirmed these documentation errors during record review.
Surveyors found expired food items in the freezer, a damaged and dirty stock pot, dusty and corroded ceiling vents above food storage areas, and meat products with visible dust and stains. Staff were also observed not following hygiene protocols, including a cook not wearing a beard restraint and a dietary aide using a sanitizing solution instead of proper handwashing.
Staff transferred a resident from wheelchair to bed by lifting under the armpits and holding the back of the pants instead of using a gait belt, as confirmed by the Director of Rehab. Additionally, a CNA observed but did not document a new skin break and redness on the resident's toe, and the LVN responsible for wound care was unaware of the change, with no documentation found in the medical record.
Two residents did not receive appropriate catheter care: one was not continuously monitored after a change in condition related to a suprapubic catheter, and another had an indwelling urinary catheter bag observed touching the floor. Staff confirmed these lapses, and documentation did not show required ongoing assessments.
A resident did not receive pain medication according to physician orders, with staff administering hydrocodone-acetaminophen 5-325 mg for severe pain and Tylenol for moderate pain, contrary to the prescribed pain management protocol. Both an LVN and the DON confirmed that the correct medications were not given for the reported pain levels.
A resident with a vascular dialysis catheter in the upper chest was assessed and care planned using interventions intended for other types of dialysis access, such as fistulas or shunts. The care plan and documentation included monitoring for bruit and thrill and other interventions not applicable to the resident's actual access type, as confirmed by nursing staff and the DON.
A resident received a controlled pain medication that was signed out on the narcotic record, but the administration was not documented on the eMAR as required by facility policy. This lapse was confirmed during a review with the DON and was not in line with the facility's procedures for medication administration and record-keeping.
Surveyors observed that a nurse left medications unattended at a resident's bedside multiple times during administration and also left a medication cart unlocked and unattended in a hallway. Additionally, a bubble pack of losartan was found to have a label that did not match the current physician's order, and no change of direction sticker was applied. These actions were not in accordance with facility policies for medication labeling and secure storage.
A resident with moderately impaired cognition was found with Flonase nasal spray at the bedside without a physician's order, assessment, or care plan for self-administration. Facility staff confirmed that required procedures for evaluating and documenting the resident's ability to self-administer medication were not followed, and the medication was accessible in a manner inconsistent with facility policy.
A resident was discharged home without the required MDS discharge assessment being completed and transmitted to CMS. Facility policy requires the MDS nurse to complete and submit all necessary assessments, but review of the medical record and staff interviews confirmed that this was not done for the discharged resident. The DON acknowledged the deficiency.
Two residents receiving nebulizer treatments for COPD were found to have their nebulizer masks stored in bags labeled with their names but not with the date of last change, contrary to facility policy requiring weekly changes and dating. Nursing staff and the DON confirmed the equipment was not dated as required.
Surveyors found that multiple facility trash bins were overfilled and had their lids open, with these conditions confirmed by the Dietary Supervisor. The bins were located in an enclosed area with the door open, contributing to unsanitary conditions.
The facility failed to ensure a complete and accurate medical record for a resident who pulled out their gastrostomy tube (GT) and had it reinserted by a physician. No Change of Condition (COC) report was completed for either event, despite the facility's policy requiring such documentation. The deficiency was confirmed through interviews and medical record reviews with the DON and Medical Records Director.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of controlled medication administration for a resident, specifically regarding hydrocodone/APAP 5-325 mg tablets. According to facility policy, when a controlled medication is administered, the licensed nurse must record the date, time, and amount administered on the accountability record, and all medications given must be documented on the Medication Administration Record (MAR). For one resident, the Tab Narcotic and Hypnotic Record showed that on one occasion, one tablet was removed from the supply, but the MAR indicated that two tablets were administered for a pain level of 7. The Director of Nursing (DON) confirmed that the nurse had accidentally signed for two tablets instead of one. On another occasion, the Tab Narcotic and Hypnotic Record showed that one tablet was removed from the supply, but there was no documentation on the MAR to indicate whether the medication was administered. The DON verified that the administration of the controlled medication was not documented as required. These discrepancies were identified through interviews, medical record reviews, and facility document reviews, and were confirmed by the DON during concurrent record review.
Unsanitary Kitchen Conditions and Improper Food Handling
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, equipment condition, cleanliness, and staff hygiene. Expired food items, including bread, hamburger buns, and English muffins, were found stored in the freezer. A large stock pot was noted to be warped, dented, and had a black substance on its inner top part. Two ceiling vents above the ice machine and freezers were dusty, corroded, and surrounded by peeling paint, with meat products stored underneath these vents observed to be dusty and stained with yellow discoloration. These findings were verified by the Dietary Supervisor and Maintenance Supervisor during the inspection. Additionally, staff were observed not following proper hygiene protocols. One cook was seen working in the kitchen without a beard restraint, and this was confirmed on two separate occasions. A dietary aide was observed placing his hands into a bucket containing sanitizing solution and a dish rag after rinsing dirty dishes, instead of performing hand hygiene at the sink. The aide acknowledged that this was not the correct process for handwashing. These actions and inactions contributed to unsanitary conditions and improper food handling practices in the kitchen.
Improper Transfer Technique and Failure to Document Change in Skin Condition
Penalty
Summary
Staff failed to provide appropriate care and treatment for a resident in two key areas. During a transfer from wheelchair to bed, two CNAs lifted the resident by placing their arms under the resident's armpits and holding the back of the resident's pants, rather than using a gait belt as required. The Director of Rehab confirmed that a gait belt should have been used and that there was no gait belt available in the resident's room at the time of the transfer. The CNAs stated they had been trained by therapy to transfer the resident in this manner, despite facility policy and standard practice. Additionally, a change in the resident's skin condition was not documented as required by facility policy. The resident was found to have a superficial break in the skin and redness on the right big toe. The LVN responsible for wound care was unaware of this change, and the CNA who observed the wound during the resident's morning shower did not document it. Review of the medical record confirmed there was no documentation of the change in skin condition.
Failure to Provide Appropriate Catheter Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care and services for residents with indwelling urinary catheters, as evidenced by two specific incidents. In the first case, a resident with a suprapubic urinary catheter experienced a change in condition when the catheter was not draining. Although the issue was identified and the resident was sent to the hospital and returned with a new catheter and antibiotics for a UTI, there was no documented evidence that licensed nurses continued to monitor or assess the resident's condition as required by facility policy. Both the LVN and DON confirmed that ongoing monitoring every shift for 72 hours following a change in condition was not performed, which was necessary to observe for complications or infection. In the second case, another resident with an indwelling urinary drainage catheter was observed with the catheter bag touching the floor. This was verified by an LVN, who acknowledged that the catheter bag should not be in contact with the floor. The resident was dependent on staff for activities of daily living and had the catheter in place for wound management. These lapses in catheter care and monitoring were directly observed and confirmed through staff interviews and medical record reviews.
Failure to Administer Pain Medication per Physician Orders
Penalty
Summary
The facility failed to provide adequate and appropriate pain management for one resident by not administering pain medication according to the physician's orders. The resident had clear physician orders for different pain medications based on the severity of pain, as indicated by a pain scale. Specifically, Tylenol 325 mg was to be given for mild pain, hydrocodone-acetaminophen 5-325 mg for moderate pain, and hydrocodone-acetaminophen 10-325 mg for severe pain. However, medical record review showed that the resident received hydrocodone-acetaminophen 5-325 mg for pain levels of eight, which was outside the prescribed range for that medication, and Tylenol for a pain level of six, which was also not in accordance with the physician's order. Interviews with both an LVN and the DON confirmed that the resident did not receive the correct medication for the reported pain levels and that the physician's orders were not followed. The facility's policy required medications to be administered as prescribed by the attending physician, but this was not adhered to in this case. The resident was documented as having the capacity to understand and make decisions, and the failure to follow the medication orders was verified through both medical record review and staff interviews.
Inaccurate Dialysis Care Planning and Assessment for Resident with Vascular Catheter
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with a vascular dialysis catheter in the right upper chest. The resident's care plan and medical records included interventions and assessments that were not applicable to the type of dialysis access present. Specifically, the care plan and post-dialysis documentation referenced monitoring for bruit and thrill, which are relevant for arteriovenous fistulas or shunts, not for vascular catheters. Additionally, interventions such as not drawing blood or taking blood pressure on the arm with a graft, and checking the fistula daily, were included despite the resident not having these types of access. Interviews with nursing staff, the MDS Coordinator, and the DON confirmed that the care plan and documentation contained inaccurate and inapplicable interventions for the resident's actual dialysis access. The errors were attributed to the use of a care plan library in the electronic health record, where inappropriate interventions may have been selected. The resident's records and care plan were not accurately individualized to reflect the specific type of dialysis access, leading to the potential for inappropriate care.
Failure to Document Controlled Medication Administration on MAR
Penalty
Summary
The facility failed to provide necessary pharmaceutical services in accordance with its own policies and procedures for one resident. Specifically, the facility's policy required that when a controlled medication is administered, the licensed nurse must immediately document the date and time of administration, the amount administered, and their signature on the accountability record, as well as ensure all current drug and dosage schedules are recorded on the resident's electronic medication administration record (eMAR). For one resident, there was a physician's order for hydrocodone-acetaminophen to be administered as needed for pain. On a specific date and time, one tablet of this controlled medication was dispensed and signed out on the Narcotic and Hypnotic Record. However, review of the resident's July medication administration record (MAR) did not show documentation that the hydrocodone-acetaminophen was administered at the recorded time. This omission was verified during an interview and concurrent medical record review with the Director of Nursing (DON). The lack of documentation on the MAR was not in accordance with the facility's established policies for controlled medication administration and record-keeping.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Surveyors identified multiple deficiencies related to medication management and storage. During a medication administration observation, a nurse was found to have left a tray of prepared medications unattended at a resident's bedside on several occasions while retrieving additional items such as a straw, spoon, and tissue paper. The resident was in bed with a family member present, and the medications, including a nasal spray, were left unsupervised each time the nurse left the bedside. Additionally, the nurse was observed leaving the medication cart unlocked and unattended in the hallway while entering the nurses' station, with non-licensed staff passing by. Further review revealed that the label on a bubble pack of losartan did not match the current physician's order. The label instructed to hold the medication if the systolic blood pressure (SBP) was more than 130 mmHg, while the physician's order specified to hold if SBP was less than 130 mmHg. The nurse confirmed the discrepancy and acknowledged that a change of direction sticker had not been placed on the medication packaging. Facility policies required accurate labeling and secure storage of medications, but these were not followed in the observed instances.
Failure to Assess and Authorize Self-Administration of Medication
Penalty
Summary
A resident was observed with a Flonase nasal spray medication at their bedside without a physician's order, assessment, or care plan authorizing self-administration of the medication. The facility's policy requires that residents who wish to self-administer medications must be assessed by the interdisciplinary team, and if deemed appropriate, this must be documented in the resident's chart. Additionally, the policy states that residents should be instructed on proper administration and that medication storage must comply with state and federal requirements. In this case, none of these steps were followed for the resident in question. Medical record review showed that the resident had a BIMS score of 12, indicating moderately impaired cognition. During interviews, both an LVN and the DON confirmed that there was no physician's order for the Flonase, no order to self-administer, no self-administration assessment, and no care plan in place for the medication. The LVN also noted that the medication should not have been at the bedside due to the risk of access by other residents. These findings were verified through observation, interview, and review of facility policy and the resident's medical record.
Failure to Complete and Transmit MDS Discharge Assessment
Penalty
Summary
The facility failed to complete and transmit a Minimum Data Set (MDS) discharge assessment for one nonsampled resident who was discharged home. According to the facility's policies and procedures, the MDS nurse is responsible for scheduling and completing all required assessments, including discharge assessments, and ensuring that encoded, accurate, and complete MDS data are electronically transmitted to the CMS system. Review of the closed medical record for the resident showed that although there was a physician's order for discharge and arrangements for home health services and equipment, there was no evidence that the MDS discharge assessment was completed at the time of discharge. During interviews, the MDS Coordinator confirmed that the discharge assessment should have been completed and submitted to CMS within the required timeframe, and acknowledged that the system used by the facility is designed to track due dates for assessments. The MDS Coordinator verified that the discharge assessment was not completed for the resident, and explained that failure to complete and submit the assessment would result in the resident appearing as still present in the facility and the assessment being marked as missed. The Director of Nursing also acknowledged these findings.
Failure to Change and Date Nebulizer Masks and Bags as Required
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required nebulizer treatments for chronic obstructive pulmonary disease (COPD). During an initial tour, surveyors observed that both residents' nebulizer masks were stored in plastic bags labeled with their names but without any indication of the date the masks or bags were last changed. According to the facility's policy, nebulizer masks, tubing, and storage bags are required to be changed and dated at least every seven days to promote resident safety during oxygen administration. Medical record reviews confirmed that both residents had active physician orders for multiple inhalation medications administered via nebulizer. Interviews with nursing staff and the Director of Nursing (DON) verified that the nebulizer masks and bags were not dated as required, and staff acknowledged this oversight. The failure to date and regularly change the respiratory equipment was not in accordance with the facility's established policies and procedures.
Overflowing Trash Bins and Improper Waste Disposal
Penalty
Summary
Surveyors observed that three out of five facility trash bins were overfilled with trash and had their lids open. These observations were made during the morning hours, with the trash bins located in an enclosed area surrounded by a wooden fence, where the door was found open and at least one bin was visible with the lid open and trash overflowing. During a concurrent interview, the Dietary Supervisor confirmed that the facility's trash bins were overfilled and had their lids open, verifying the unsanitary condition observed by surveyors. No information about residents or their medical conditions was provided in relation to this deficiency.
Failure to Document Change of Condition
Penalty
Summary
The facility failed to ensure a complete and accurate medical record for one of the sampled residents. Specifically, there was no Change of Condition (COC) report completed when the resident pulled out their gastrostomy tube (GT) and when the GT was reinserted by the physician. This failure was identified during a review of the facility's policies and procedures, which indicated that any change in a resident's condition should be documented in the eInteract Change of Condition. The deficiency was confirmed through interviews and medical record reviews with the Director of Nursing (DON) and the Medical Records Director. The resident in question had severe cognitive impairment and was noted to be agitated during the night, leading to the removal of the GT. The emergent replacement of the GT was performed by a physician, but the medical record did not reflect a COC report for either the removal or the replacement of the GT. The DON acknowledged that a COC report should have been completed for both events. The Medical Records Director further explained that the Licensed Vocational Nurse (LVN) should initiate the COC, and the Registered Nurse (RN) should follow up by contacting the physician and noting new orders, with subsequent monitoring of the resident every shift for 72 hours after the incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 2,890 citations issued within 25 miles in the last 12 months — including the 8 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Costa Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Newport Subacute Healthcare Center | 0.8 mi | ★★★★★ | 50 | 0 |
| Mesa Verde Post Acute Care Center | 1.4 mi | ★★★★★ | 25 | 0 |
| Newport Nursing And Rehabilitation Center | 1.9 mi | ★★★★★ | 11 | 0 |
| Pelican Ridge Post Acute | 2 mi | ★★★★★ | 62 | 0 |
| Crystal Cove Care Center | 2.1 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Victoria Healthcare And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.