Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Crossing Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including post-amputation orthopedic aftercare, osteomyelitis, COPD, and muscle weakness, was discharged home with a PT note indicating home health was recommended, but without documentation that these services were arranged or that required discharge planning steps were completed. The resident filed an appeal with DCF, asserting they were being erroneously discharged, yet the EMR contained no documentation of the appeal, no AHCA discharge/transfer form, and no discharge summary. The SSD confirmed the absence of these records, and the NHA acknowledged that Social Services should document discharge assessments and that residents who appeal should not be discharged until an appeal decision is made, but stated that coverage gaps in Social Services led to discharge processes not being done correctly.
A resident admitted with post-amputation orthopedic aftercare, osteomyelitis of the left ankle and foot, COPD, and muscle weakness was discharged without required discharge documentation. Record review showed no AHCA discharge/transfer form, no documented discharge notifications or reason for discharge, no discharge summary, and no post-discharge plan of care, despite facility policy requiring these elements. The SSD confirmed the absence of appeal and discharge documentation, and the NHA acknowledged that social services staff responsible for discharge planning and resident notification had not completed the required assessments and notes.
A resident who was always incontinent of bowel and bladder, had multiple comorbidities, and was on diuretic therapy reported remaining wet for extended periods and typically not being changed until late morning. Surveyors observed the resident in bed with a noticeable urine odor in the room and later noted excoriation in the groin area, although the brief was dry at that moment. Staff stated that CNAs should round every 2–3 hours, check heavy wetters more often, and document toileting and incontinence care as it occurs, but a 14‑day review of CNA documentation showed multiple missing and inconsistent entries across shifts. The unit manager and DON confirmed that toileting episodes were not consistently documented and acknowledged that undocumented care is considered not done.
Failure to Assess and Order Self-Administration of Medications: Two residents were observed self-administering medications without documented nurse assessment or provider orders. One resident with severe cognitive impairment swallowed 10 oral tablets left at bedside while no staff were present, and another resident with intact cognition used a nebulizer mask and machine left within reach without staff in the room. The DON and LPN/UM stated self-administration required an assessment and provider order, but neither resident had one, and neither was listed among the facility’s two approved self-administering residents.
Failure to Provide Meal Menus and Honor Resident Choice: Multiple residents stated they were no longer given meal menus in their rooms and did not know what would be served until trays arrived, preventing pre-ordering of alternate meals. One resident reported repeated unmet requests for a cheeseburger and showed meal tickets with handwritten choices and requests for fresh fruit. The CDM said menus were stopped because some residents ordered items like toast or bread, and staff stated residents could not pick what they wanted.
PASRR screening was not updated appropriately for two residents with mental health or cognitive diagnoses. One resident had documented psychotic disorder, bipolar disorder, anxiety, dementia, hallucinations, and paranoid thoughts, yet the Level I PASRR marked all screening questions no and stated no SMI or ID was indicated; the DON later said dementia should have been marked yes and a Level II PASRR was needed. A second resident’s PASRR from the acute care hospital did not include adjustment disorder with depressed mood that was listed in the admission record.
Failure to provide nail trimming as part of ADL care for a resident with CVA, cerebral amyloid angiopathy, weakness, coordination deficits, and dementia. The resident was observed with long untrimmed nails and black build-up underneath and stated that staff had not trimmed the nails despite requests. The care plan included checking nail length and trimming and cleaning nails on bath day as needed, while staff reported nail trimming was done only when requested or noticed and was not consistently documented.
The facility failed to follow physician orders for two residents. One resident received Midodrine even when SBP was above the ordered hold parameter, and the record lacked documentation showing physician approval for overriding the order. Another resident with CHF, DM, and CKD had ordered ammonium lactate lotion for both lower legs, but staff did not apply the cream as ordered, and an LPN/UM observed dry, flaky skin with sores, drainage, and odor on both calves. The skin/wound records did not reflect the observed lower leg condition, and staff stated no physician or family notification and no CIC had been documented.
Failure to maintain nutritional status for three residents: one resident reported ongoing hunger and had significant wt loss with poor intake of an ordered shake, another resident with dysphagia did not receive ordered supplement intake and had limited wt monitoring, and a third resident stated he disliked the food and had major wt loss. Staff observations showed dated water cups left at the bedside, fluids/snacks were offered only once or twice in 30 days, and the DON/RD were unaware of the poor intake and wt loss.
Medication administration errors caused the facility’s error rate to exceed 5%. An LPN gave a resident a nebulizer medication labeled for another resident and was stopped before completing the dose, while another LPN administered oral meds and insulin to a resident but could not locate ordered sevelamer and hydromorphone on the cart or in the med dispenser, with doses documented late or unavailable. The DON agreed with the findings, and the report noted the facility’s policies did not address how to reorder meds to prevent missed doses.
Food service safety standards were not followed in the kitchen, walk-in fridge/freezer, dry storage, and nourishment rooms. The DD confirmed multiple items were unlabeled or improperly stored, including milk, pork loins, frozen foods, juice, thickener, and other resident food items, and a prep-area garbage can was nearly overflowing and uncovered. Staff were also observed changing tasks on the tray line and in dish areas without performing hand hygiene or proper glove changes, and one DA stated she did not perform proper hand hygiene and glove use.
The facility did not ensure that staff were trained and available on all shifts to manually transfer power to the standby generator, which is necessary to maintain safe indoor temperatures during a power outage. The lack of training and absence of a designated individual to perform this task resulted in noncompliance with emergency environmental control requirements.
A facility failed to ensure proper infection control practices, including PPE use and hand hygiene, on one unit. A nurse did not perform hand hygiene after administering medication, and a visitor and staff member were observed in a resident's room with contact precautions without PPE. Confusion among staff about PPE use for a resident with a UTI and ESBL resistance was noted. The order for contact precautions was delayed, and the facility's infection control policies were not followed.
The facility failed to notify the family and physician of a change in condition for two residents. One resident, with multiple diagnoses, was confused and called family for help, leading them to call 911. Despite the family's request, the night nurse refused to send the resident to the hospital, and there was no documentation of a change in condition or physician notification. The second resident had a leg wound, but there was no documentation of a change in condition or notification to the physician and family.
A resident with a history of diabetes and bilateral amputations was found with untreated wounds, including a necrotic eschar on the right stump. The resident reported pain and lack of care, and it was confirmed that the wound care team was not involved, and no orders were in place. The facility lacked documentation of skin sweeps, physician, and family notifications, and did not have a Wound Care or Skin Assessment Policy.
A facility failed to provide dialysis care per physician orders for a resident dependent on renal dialysis. The resident's care plan required site assessments, bleeding checks, and vital sign monitoring, but documentation was incomplete on several occasions. Interviews with an LPN and the DON confirmed the need for proper documentation, which was not consistently done, and a dialysis policy was not provided when requested.
Failure to Honor Discharge Appeal and Document Discharge Planning
Penalty
Summary
Surveyors identified that the facility failed to allow a resident to remain in the facility during a pending discharge appeal. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, other acute osteomyelitis of the left ankle and foot, COPD, and muscle weakness, and had a care plan goal to return home with family once able to verbalize needed assistance and required services post-discharge. The care plan directed Social Services to encourage the resident to discuss concerns impeding discharge, establish a pre-discharge plan, and arrange community resources to support independence after discharge. A PT discharge summary covering the stay indicated the plan was for the resident to discharge home at the highest practical level with recommended home health services, but the summary did not document whether those home health services were actually arranged prior to discharge. A DCF appeal hearing form showed that an appeal of the discharge was filed based on the resident’s belief that they were being erroneously discharged from the facility. The resident’s electronic medical record contained no documentation that the resident or representative had filed an appeal, no notes explaining why the resident might not have been ready for discharge, no AHCA discharge/transfer form, and no documented discharge summary. The SSD, newly employed and unfamiliar with the case, confirmed the absence of any appeal-related documentation and required discharge forms in the record. The NHA stated that Social Services is responsible for discussing discharges, completing assessments, and documenting discharge notes, and acknowledged that if a resident files an appeal, they should not be discharged until after the appeal decision, but also acknowledged that coverage gaps in Social Services led to discharge processes not being completed correctly. The facility’s discharge planning policy required a process focused on resident discharge goals, support system, and transition timing to ensure a smooth process, which was not reflected in the documentation for this resident.
Failure to Document Required Discharge Notifications and Summary
Penalty
Summary
The facility failed to complete and document required discharge and transfer notifications, including the reason for discharge, for one resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, other acute osteomyelitis of the left ankle and foot, COPD, and muscle weakness, and was later discharged. Review of the electronic medical record showed no documentation of the required discharge elements per facility policy, including the AHCA discharge/transfer form, discharge notifications, or the reason for discharge. There was also no documented discharge summary or evidence of a post-discharge plan of care. During interviews, the Social Services Director stated they had only worked at the facility for one week, did not know the resident, and were unaware of any discharge appeal. After reviewing the record, the Social Services Director confirmed there was no documentation of an appeal, no AHCA discharge/transfer form, and no discharge summary. The Nursing Home Administrator stated that social services is responsible for discussing discharge with residents, conducting an assessment, documenting notes related to discharge, notifying residents at least two days before discharge, and documenting a meeting about the discharge plan. The Nursing Home Administrator acknowledged that there was nothing in the record related to the discharge and explained that the facility did not have a dedicated social services staff member at the time and that coverage staff were not completing the required discharge documentation correctly. Review of the facility’s Discharge Planning policy confirmed that a discharge summary and post-discharge plan of care are required but were not present in this case.
Failure to Provide and Document Timely Incontinence and Toileting Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of toileting and incontinence care for a resident who was always incontinent of bowel and bladder and required assistance with turning, repositioning, personal hygiene, and toileting. The resident, who had diagnoses including arthritis, COPD, and heart failure and was on diuretic therapy for edema, reported being wet and not having been changed since 5:00 a.m., and stated that staff typically did not change them until they were dressed around 11:00 a.m. During a morning observation, the resident was found lying in bed and reported being wet, and on another morning observation, there was a noticeable urine odor in the resident’s room while the resident was in bed eating breakfast. The resident reported having open areas in the groin and using a medicated barrier cream they had purchased, while the facility provided another type of barrier product. During an observed assessment of the groin area with an LPN, the resident’s incontinence brief appeared dry at that time, but the groin area outside the brief was excoriated, and the LPN then provided incontinence care. Staff interviews indicated that CNAs were expected to receive report from the prior shift, round on residents in the morning to ensure they were clean, and check residents for incontinence every 2–3 hours, with more frequent checks for heavy wetters. Staff also stated that if a resident refused to be changed, they were to re-approach and involve additional staff and a nurse if refusals continued, and that this resident was able to make needs known. Review of the CNA documentation for bladder function over a 14‑day lookback period showed multiple gaps and inconsistencies in recorded episodes of continence and incontinence across all three shifts. There were instances where several episodes of incontinence were documented within short time frames, followed by long periods with no documentation for an entire shift or more than 14–24 hours between entries. The unit manager and DON both stated that CNAs were supposed to document toileting and incontinence care as it occurred, that staff should be rounding every two hours and per resident request, and confirmed that toileting episodes were not consistently documented. The DON acknowledged that if care was not documented, it was considered not done, highlighting missing documentation for toileting and incontinence care for this resident.
Failure to Assess and Order Self-Administration of Medications
Penalty
Summary
The facility failed to ensure two residents were assessed and had physician orders in place before being allowed to self-administer medications. One resident was observed in bed with an over-bed table within reach and a medication cup containing 10 oral tablets sitting on the table. The resident stated the medication had just been given and that the resident would take it, then reached for the cup and swallowed all of the tablets at one time while no staff member was in the room. That resident’s record showed diagnoses including acute and chronic respiratory failure with hypoxia, blindness in one eye, alcohol abuse, and cannabis abuse, and the quarterly MDS showed a BIMS score of 5 of 15 indicating severe cognitive impairment. The resident’s physician orders and care plan did not include self-administration of medications. A second resident was observed lying in bed wearing a nebulizer mask with the nebulizer machine within reach on the over-bed table, and no staff member was in the room or visible in the hallway. The resident turned the machine off, reported getting a nebulizer treatment, and then turned it back on. That resident’s record showed diagnoses including chronic respiratory failure with hypoxia, COPD with acute exacerbation, and emphysema, and the quarterly MDS showed a BIMS score of 14 of 15 indicating intact cognition. The resident’s physician orders did not include permission for self-administration, and the care plan did not include a focus or intervention related to assessment for self-administration. Interviews with the DON and LPN/UM showed the facility expected a self-administration assessment and physician order before residents could self-administer medications, and staff stated nebulizer treatments were considered medications. The DON stated medications left at bedside were against the medication administration policy and competency, and that nurses should be present during nebulizer treatments. The facility provided a list of two residents assessed to self-administer medications, but neither of the two residents observed was on that list, and the facility did not provide a self-administration assessment for either resident.
Failure to Provide Meal Menus and Honor Resident Choice
Penalty
Summary
The facility failed to provide meal menus to four residents reviewed for choice, and residents stated they no longer received menus in their rooms or on their walls or overbed tables. Resident #24 said menus had not been passed out in a while and she did not know what she would be served until the tray arrived. Resident #67 stated menus were no longer provided, so they could not know what was being served ahead of time or pre-order an alternative meal. Resident #110 also stated they did not know the meal before the tray arrived and could not pre-order an alternative meal because menus were no longer provided in resident rooms. Resident #105 reported not receiving the food requested, including repeated requests for a cheeseburger, and said they had only received one cheeseburger in the month they had been at the facility. The resident also showed a meal ticket with lunch and dinner items for one day and breakfast for the next, along with handwritten meal choices and requests for fresh fruit. The Dietitian and Certified Dietary Manager stated the contracted kitchen vendor had stopped passing out lunch menus because residents were ordering items such as toast or bread, which they did not consider a nutritional meal. Staff also stated residents no longer received meal menus and could not pick what they wanted, while the facility policy stated residents should receive food that accommodates preferences and appealing options of similar nutritive value when they request a different meal choice.
PASRR Screening Not Updated for Residents With Mental Health and Cognitive Diagnoses
Penalty
Summary
PASRR screening was not updated appropriately for two residents with mental health or cognitive diagnoses. For one resident, the record showed diagnoses including psychotic disorder with hallucinations due to a known physiological condition, bipolar disorder, generalized anxiety disorder, unspecified dementia, primary insomnia, and other frontotemporal neurocognitive disorder. The resident was observed stating that Spanish-speaking people were talking about him and accusing him of molesting his daughter, and the care plan documented paranoid thoughts, visual and auditory hallucinations, depression, and impaired cognitive function related to dementia. The Level I PASRR for this resident marked questions 1 through 7 as no and indicated that no diagnosis or suspicion of serious mental illness or intellectual disability was present, with Level II evaluation not required. During interview, the DON reviewed the PASRR and stated that question 2a regarding interpersonal functioning should have been marked no because the resident could express needs and wants, and question 7 should have been marked yes for dementia. The DON further stated the resident needed to be screened for a Level II PASRR. For a second resident, the PASRR completed at the acute care hospital did not include the diagnosis of adjustment disorder with depressed mood that was documented in the admission record. The NHA stated the facility had just updated the PASRR to include the missing diagnosis. The facility policy required residents to be screened for mental disorder or intellectual disability prior to admission and to complete Level II screening when the Level I screen was positive.
Failure to Provide Nail Trimming as Part of ADL Care
Penalty
Summary
The facility failed to provide ADL assistance related to fingernail trimming for one resident who was unable to perform the task independently. Resident #135 was admitted on 01/02/2026 with diagnoses including cerebral infarction, cerebral amyloid angiopathy, muscle weakness, unspecified lack of coordination, and need for assistance with personal care. The resident’s care plan dated 01/03/2026 identified an ADL self-care performance deficit related to CVA, cerebral amyloid angiopathy, dysarthria, right hemiparesis, and dementia, and included an intervention to check nail length and trim and clean nails on bath day as necessary. During observation and interview, Resident #135 was noted to have long untrimmed nails with black build-up underneath and stated a desire for the nails to be trimmed, saying they did not like them being that long and had asked staff to trim them but it had not been done yet. Staff interviews indicated there was no set schedule for nail trimming, that it was done when residents asked or when staff noticed it, and that nail trimming was normally documented on shower sheets that were not always completed as they should be. The DON stated the expectation was for residents’ nails to be trimmed with showers or as needed.
Failure to Follow Medication Parameters and Ordered Skin/Wound Care
Penalty
Summary
The facility failed to follow physician orders for medication administration for one resident with hepatic failure, portal hypertension, hypotension, and a history of thrombosis and substance abuse. The resident’s order for Midodrine 15 mg by mouth three times daily for hypotension included a hold parameter if systolic blood pressure was greater than 130. Review of the MAR showed the medication was administered on multiple occasions when the resident’s systolic blood pressure was above that limit in both November and December 2025. During interview, the DON reviewed the MAR and stated the Midodrine should have been held when the blood pressure was greater than 130. The physician stated that if medication was given outside the order parameters, there should have been a nurse’s note documenting that the nurse spoke with a physician and received approval, but the record review did not identify such documentation in the report. The facility policy stated that physician orders are to be administered upon the clear and complete order of an authorized prescriber. The facility also failed to provide and document ordered skin and wound care for another resident with CHF, type 2 diabetes, difficulty walking, CKD stage 5, and a BIMS score of 12. The resident stated staff had not been applying prescribed cream to the calves for several days, and an LPN/UM observed dry, flaky skin with sores and wounds on both calves with drainage and a strong odor. The resident had an order for ammonium lactate lotion to be applied daily and every evening to both lower legs, but the skin evaluation and wound reports referenced heel wounds and did not include the observed bilateral lower leg skin condition or the lotion order. Staff stated no report had been made to the physician or family representative, and no change in condition was documented, while the DON stated documentation, physician notification, a CIC, and a risk assessment were expected.
Failure to Maintain Nutritional Status and Provide Ordered Fluids/Supplements
Penalty
Summary
The facility failed to maintain acceptable nutritional status for three residents by not providing food and fluids as documented and by not responding to significant weight loss and poor intake. Resident #1, who had diagnoses including Type 2 diabetes mellitus, generalized muscle weakness, and assistance with personal care, was observed on multiple occasions with a foam water cup dated from prior days on the bedside table. During interview, the resident said he was still hungry and had asked for another breakfast tray but had not received one. His record showed a weight loss from 137.3 pounds to 121.6 pounds, a loss of 15.7 pounds or 11.43%, and he was ordered a 4-ounce health shake that he consumed at an average of only 25% in January 2026. Resident #71, who had diagnoses including Type 2 diabetes mellitus and dysphagia, was also observed with dated foam water cups on the bedside table on separate days. The record showed only one documented weight of 179 pounds on admission, and the resident was ordered eight ounces of a high-calorie supplement daily but did not consume the supplement in January 2026. Resident #113, who had generalized muscle weakness and oropharyngeal phase dysphagia, stated he did not like the food and thought he had lost weight. His weight decreased from 150.8 pounds to 124.2 pounds, a loss of 26.6 pounds or 17.64%. For all three residents, task records showed fluids and snacks were offered only once or twice in the prior 30 days rather than daily. Progress notes showed no attempted contact with the MD or RD for Resident #1 or Resident #113 despite the documented weight loss and poor intake. The RD and DON stated they were unaware of the residents’ poor intake, lack of daily fluids and snacks, and significant weight loss, and the DON stated nurses were responsible for providing ordered dietary supplements. The facility policy required appealing food options, drinks sufficient to maintain hydration, accurate and timely weights, and weekly weight monitoring for newly admitted residents.
Medication Error Rate Exceeded 5 Percent
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5.00%. During 25 observed medication administration opportunities, surveyors identified 3 errors involving 2 residents, resulting in a 12.00% medication error rate. The deficiency was based on direct observations, record reviews, and interviews with staff and the DON. During one observation, an LPN administered medications to a resident with COPD, CHF, and abnormal lung findings, including oral medications and insulin, and then attempted to administer ipratropium-albuterol from a vial labeled for another resident. The staff member removed the vial from a box labeled for a different resident, prepared the nebulizer medication, and was stopped before completing administration. The LPN acknowledged the medication was not prescribed for that resident and stated she would normally not take medication from another resident. During another observation, an LPN administered oral medications and insulin to a resident with ESRD, CHF, and cannabis use, but the resident’s sevelamer and hydromorphone were not available on the cart. The staff member located insulin in a medication refrigerator on another unit, found sevelamer was not stocked in the electronic medication dispenser, and found hydromorphone was a stock medication but unavailable in the dispenser. The MAR and progress notes showed the resident received sevelamer late and hydromorphone doses were documented as unavailable, with notes indicating the medication was pending delivery from pharmacy and no clear documentation that the pharmacy or physician was notified.
Food Storage and Hand Hygiene Deficiencies
Penalty
Summary
Food service safety standards were not followed in the kitchen, walk-in refrigerator, walk-in freezer, dry storage area, and nourishment rooms. During observations, the Dietary Director confirmed multiple items were not properly labeled or stored, including an opened unlabeled gallon of milk, thawed pork loins without an open date or pull date, an open box of cinnamon rolls, twist-tied chicken patties without a label, open-to-air boxes of chicken nuggets and beef patties without open dates, freezer-burned hot dogs without a stored or opened date, and an opened rusted can of juice covered with loose plastic wrap and no open date. In the kitchen prep area, a garbage can was observed almost overflowing and without a lid, and the Dietary Director stated it should have been emptied and covered tightly. Additional observations in the kitchen prep line showed a bag of bread and a Ziplock bag of marshmallows without open dates. In the nourishment room on the 200 hall, multiple items were observed unlabeled or improperly stored, including an open carton of 2% milk, an open bottle of water, opened containers of liquid thickener with open dates of 10/25 and 12/25, an opened bottle of goat milk, a pitcher of juice one-third full with no label, a soup bowl from the kitchen with no date or owner identified, and a grocery bag of chili with no label indicating when it was stored or who it belonged to. The refrigerator in that room also had multiple dried spills throughout and in the drawers. A second nourishment room had similar findings, including an open unlabeled carton of 2% milk, a pitcher of juice one-third full with no label, a soup bowl from the kitchen with no date or owner identified, and a container of protein shake with no open date or owner identified, along with dried spills in the refrigerator and drawers. Hand hygiene was also not performed during task changes. Staff K was observed prepping food, changing food thermometers, pureeing bread, making a grilled cheese, and throwing away garbage while returning to the tray line without performing hand hygiene between tasks. Staff U was observed placing drinks on trays, stacking trays on food transporters, and performing dish area tasks between building trays without hand hygiene in between task changes or before returning to the tray line. During interview, Staff U stated she did not perform proper hand hygiene and glove use. The Dietary Director stated the expectation was for hands to be washed before and after each glove change and for gloves to be changed before and after each change of task, and that food items must have receive dates and opened dates and be covered and closed so there are no openings.
Failure to Ensure Trained Staff for Manual Emergency Power Transfer
Penalty
Summary
The facility failed to ensure that emergency power could be transferred to maintain safe indoor temperatures in the event of a loss of primary electrical power. During a review of the Comprehensive Emergency Management Plan (CEMP) and the generator/cooling plan, it was found that the facility only had a manual option to transfer power to the standby generator, which is responsible for supplying emergency power to the air conditioning system in designated cool zones. There was no evidence provided that an on-site and trained individual was available during all shifts to perform the manual transfer of power to the standby generator. This gap in staffing and training meant that, in the event of a power outage, there was no assurance that the generator could be activated promptly to maintain required temperatures for resident safety and comfort. Interviews with the Administrator and the Human Resource officer confirmed that staff had not been trained to perform the manual transfer of power. Additionally, it was stated that this training was not included as part of the emergency plan for new employee orientation. This lack of training and preparedness directly contributed to the facility's inability to meet the licensure requirement for emergency environmental control.
Infection Control Deficiency in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices on one of its units, specifically regarding the use of personal protective equipment (PPE), the timeliness of contact precaution orders, and hand hygiene. During an observation, a registered nurse did not perform hand hygiene after administering medication to a resident and before touching the medication cart. Additionally, a visitor and an unknown staff member were observed in a resident's room, which had a Contact Precaution sign, without wearing any PPE. Interviews revealed confusion among staff regarding the necessity of PPE when entering the room of a resident on contact precautions for a urinary tract infection (UTI) with extended spectrum beta lactamase (ESBL) resistance. The resident in question was admitted with diagnoses including a UTI, ESBL resistance, and was a carrier of methicillin-resistant Staphylococcus aureus. Lab results confirmed the presence of Escherichia coli and ESBL in the urine, which were reported to the facility, but the order for Isolation Contact Precautions was not entered until a day later. The Director of Nursing confirmed that staff should perform hand hygiene immediately upon exiting a resident's room and that PPE should be worn anytime someone enters a room with contact precautions. The facility's policies on infection control and isolation protocols were not adhered to, contributing to the deficiency.
Failure to Notify Family and Physician of Change in Condition
Penalty
Summary
The facility failed to notify the family and physician of a change in condition for two residents. For the first resident, who had multiple diagnoses including acute respiratory failure and Alzheimer's disease, there was a lack of documentation and communication regarding his condition. The resident was confused and repeatedly called family members for help, prompting them to call 911. Despite the family's request to send the resident to the hospital, the night shift nurse refused, stating the resident was fine. The resident later refused to be transferred by EMTs, and there was no documentation of a change in condition, physician notification, or interventions to address his needs. The Assistant Director of Nursing later noted a positive urine culture for a UTI, but there was no documentation of care or monitoring prior to the resident's death. Interviews with staff revealed a lack of documentation and communication with the physician and family. The Director of Nursing confirmed the absence of documentation regarding family notification and physician contact. The Medical Director and ARNP also did not recall being informed of the family's concerns or the resident's refusal of treatment. For the second resident, who had a history of diabetes and end-stage renal disease, the facility failed to notify the family and physician of a leg wound. The resident's skin evaluation revealed a dark area with a small opening on the right stump, but there was no documentation of a change in condition or notification to the physician and family. Interviews with staff confirmed that a change in condition should have been completed and the provider notified, but this was not done.
Failure to Provide Wound Care and Assessments
Penalty
Summary
The facility failed to provide appropriate wound assessments and care for a resident with wounds, as observed during a survey. The resident, who had a history of type 2 diabetes mellitus, end-stage renal disease, and bilateral below-knee amputations, was found to have a scab with small spots of blood on the left knee and a large area of necrotic eschar with small open areas of slough on the right lower extremity stump. The resident complained of pain and reported that she had informed the nurses about her need for wound care, but no action was taken. Upon review, it was confirmed that the wound care team was not following the resident, and there were no wound care orders in place. Further investigation revealed that the facility lacked documentation of skin sweeps, physician notification, and family notification regarding the resident's condition. The resident's care plan included interventions for skin integrity and pressure injury prevention, but these were not followed. The Director of Nursing acknowledged that the resident should have had wound care orders and assessments, and the Nursing Home Administrator admitted that the facility did not have a Wound Care Policy or a Skin Assessment Policy in place.
Failure to Provide Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide Hemodialysis (HD) care per physician orders for a resident dependent on renal dialysis. The resident was admitted with a diagnosis of renal failure requiring dialysis. Physician orders required the assessment of the dialysis site for infection every shift, checking for bleeding, and monitoring vital signs. The care plan also included changing the dressing daily and ensuring the resident attended scheduled dialysis appointments. However, the review of dialysis communication forms revealed incomplete pre and post-dialysis care documentation on multiple occasions, indicating a failure to adhere to the prescribed care protocols. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that pre and post-dialysis care should be documented on the dialysis form, which was not consistently done. The LPN stated that pre-dialysis care involves checking vitals and managing medications, while post-dialysis care includes monitoring the site and documenting as ordered. Despite these requirements, the facility did not provide a dialysis policy when requested, further highlighting the deficiency in ensuring proper dialysis care and documentation for the resident.
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Illustrative
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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 Brandon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Oakfield | 1.1 mi | ★★★★★ | 23 | 0 |
| Aviata At Central Park | 1.2 mi | ★★★★★ | 3 | 0 |
| Hawthorne Center For Rehabilitation And Healing Of | 1.6 mi | ★★★★★ | 0 | 0 |
| Elon Manor Nursing And Rehabilitation Center | 9.4 mi | ★★★★★ | 10 | 0 |
| Whispering Oaks | 9.5 mi | ★★★★★ | 11 | 0 |
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