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 Nursing & Rehabilitation Center, Inc. during CMS and state inspections, most recent first.
A resident with a history of falls and moderate cognitive impairment was left unsupervised in a high-positioned bed with only one floor mat in place, contrary to the care plan requiring the bed to remain low and bilateral floor mats to be used. A CNA raised the bed and removed a mat for care, then left the resident unattended while retrieving linens, resulting in a failure to follow established fall prevention interventions.
A resident with a history of falls and moderate cognitive impairment was found unattended in a high-positioned bed with only one floor mat in place, contrary to physician orders and care plan interventions requiring bilateral floor mats and the bed to remain in the lowest position. The CNA left the resident unsupervised while retrieving linens, resulting in a deficiency related to accident hazards and inadequate supervision.
The facility failed to ensure resident privacy and confidentiality, as evidenced by an LPN leaving a medication cart computer screen unlocked and an RN not providing privacy during medication administration. The LPN left the screen open due to an emergency, while the RN did not close the door or pull the curtain, leaving a resident visible from the nursing station.
The facility failed to complete accurate Level I PASRRs for two residents, omitting diagnoses of Generalized Anxiety Disorder and Major Depressive Disorder. One resident's PASRR did not include anxiety despite clinical records and medication orders indicating its presence. Another resident's PASRR omitted depression, although clinical records and prescriptions supported the diagnosis. Staff interviews revealed errors in the PASRR process, with the Director of Social Services and APRN acknowledging the omissions.
A resident with chronic conditions was found without a nasal cannula, leading to low oxygen saturation levels. The RN confirmed the resident's oxygen was prescribed continuously at 2 L/min, but the nasal cannula was removed during a transfer by a CNA without notification. The resident's saturation improved after reapplication. The facility's policy on oxygen administration was not consistently followed, as indicated by staff interviews.
The facility failed to properly store medications for four residents, with items like nasal sprays, sore throat medicine, and shampoos found at bedsides. Staff confirmed these should not be at bedside, revealing a lack of clarity and enforcement of the facility's medication storage policy.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
A deficiency was identified when a resident with a history of falls and moderate cognitive impairment was found lying unattended in a high-positioned bed with only one floor mat in place and no staff present in the room. The resident was dependent on assistance for activities of daily living and had previously experienced a fall. Facility policy and the resident's care plan required the bed to be kept in the lowest position at all times when the resident was unsupervised, and for bilateral floor mats to be used as a fall prevention measure. During the incident, a Certified Nursing Assistant (CNA) raised the bed and removed one floor mat while providing care, then left the resident unsupervised in the high bed while retrieving linens from the hallway. The CNA stated that the bed was left elevated for proper body mechanics and that the resident was sleeping at the time. The facility's risk manager confirmed that the expectation was for the bed to remain low and the resident to be supervised if a floor mat was removed. This failure to implement the fall prevention interventions outlined in the care plan constituted the deficiency.
Failure to Maintain Fall Precautions and Supervision for At-Risk Resident
Penalty
Summary
A resident with a history of falls and moderate cognitive impairment was observed lying unattended in a high-positioned bed with only one floor mat in place, despite physician orders for bilateral floor mats and a care plan intervention requiring the bed to be kept in the lowest setting at all times. The resident was dependent on assistance for activities of daily living and had experienced a fall within the past several months. During the observation, no staff were present in the room, and the Certified Nursing Assistant (CNA) responsible for the resident was found gathering linens in the hallway. The CNA stated that while providing care, one floor mat was removed and the bed was raised for body mechanics, but the bed was left elevated and the resident unsupervised while the CNA left the room to get linens. Facility policy requires that interventions to reduce accident risks, such as keeping the bed low and ensuring supervision when safety equipment is removed, be implemented for residents at risk for falls. The failure to maintain the bed in the lowest position and to provide adequate supervision resulted in a deficiency related to accident hazards and resident safety.
Privacy Breach in Resident Care
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical records, as evidenced by two specific incidents. On December 10, 2024, a resident's information was visible on an unattended medication cart computer screen on the sixth floor. Staff A, an LPN, admitted to leaving the screen unlocked due to being called away for an emergency, despite the protocol requiring the screen to be locked when unattended. This lapse in protocol resulted in a breach of resident confidentiality. Additionally, on December 11, 2024, during a medication administration observation, Staff C, an RN, failed to provide privacy for a resident during medication administration. The RN entered the resident's room without closing the door or pulling the curtain, leaving the resident visible from the nursing station. Although the RN believed privacy was maintained due to the resident being alone in the room, the surveyor confirmed that the resident was fully visible, indicating a failure to adhere to the facility's privacy protocols. The Director of Nursing confirmed that the facility's policy requires doors to be closed and curtains pulled during medication administration in double-occupied rooms.
Failure to Complete Accurate PASRRs for Two Residents
Penalty
Summary
The facility failed to ensure accurate and timely completion of Level I Preadmission Screening and Resident Review (PASRR) for two residents, resulting in omitted diagnoses. For Resident #254, the PASRR completed on 7/24/24 did not include the diagnosis of Generalized Anxiety Disorder, despite the resident's clinical records indicating a diagnosis of Anxiety, Major Depressive Disorder, and Psychosis. The resident was observed with a tracheostomy and communicated through hand gestures. The resident's care plan and medication orders also supported the presence of anxiety, as the resident was prescribed Buspirone for Generalized Anxiety Disorder. Similarly, for Resident #266, the PASRR dated 10/9/24 omitted the diagnosis of Major Depressive Disorder. The resident's demographic sheet and clinical records indicated diagnoses of Anxiety, Major Depressive Disorder, and Psychosis. The resident was observed awake and alert, and the care plan addressed a sad mood related to depression, with interventions including medication administration and behavioral health consults. The resident was prescribed Sertraline for Major Depressive Disorder, further supporting the diagnosis. Interviews with facility staff revealed that the Director of Social Services and the APRN were responsible for reviewing and ensuring the accuracy of PASRRs. The Director of Social Services admitted to errors in the PASRR process, citing a blank PASRR from the hospital and assumptions about medication use as reasons for the omissions. The APRN confirmed the oversight, acknowledging that the diagnoses of Anxiety and Depression were not included in the PASRRs for the two residents.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to administer oxygen as ordered for a resident, resulting in decreased oxygen saturation levels. On observation, the resident was found lying in bed without a nasal cannula in place, despite an oxygen concentrator being set at 2 liters per minute. The resident's oxygen saturation level was measured at 86%, which was confirmed to be low by the attending RN. Upon reapplication of the nasal cannula, the saturation level improved to 94%. The RN revealed that the nasal cannula was removed during a transfer by a CNA, who did not notify the RN. The RN stated that they monitor residents by rounding every hour and communicate verbally with CNAs about necessary interventions. The resident, who was admitted with diagnoses including hypertensive heart and chronic kidney disease with heart failure, had a physician's order for continuous oxygen at 2 liters per minute. The care plan and medication administration record confirmed the need for continuous oxygen therapy. Interviews with staff indicated a lack of consistent communication and monitoring, as the CNA claimed to have seen the resident remove the nasal cannula and replaced it without notifying the nurse. The Director of Nursing emphasized the importance of following doctor's orders and monitoring oxygen administration, highlighting a gap in adherence to the facility's oxygen administration policy.
Improper Medication Storage at Bedside
Penalty
Summary
The facility failed to properly store medications for four residents, as evidenced by observations of various medications at the bedside of these residents. Specifically, a nasal spray was found at the bedside of one resident, sore throat medicine at another's bedside, and both ammonium lactate and ketoconazole shampoo on a nightstand of a third resident. Additionally, eye drops and nasal spray were observed at the bedside of a fourth resident. These observations were made during a survey, and staff members, including registered nurses and the Assistant Director of Nursing, confirmed that such medications should not be kept at residents' bedsides. Interviews with staff revealed a lack of clarity and enforcement regarding the facility's policy on medication storage. Staff members, including a registered nurse and the Assistant Director of Nursing, acknowledged that medications such as nasal sprays, eye drops, and medicated lotions should not be at residents' bedsides. The Director of Nursing further explained that family members often bring these items for residents, despite the facility's efforts to educate them against doing so. The facility's policy, revised in January 2024, mandates that all drugs and biologicals be stored in locked compartments, yet the survey findings indicate a failure to adhere to this policy.
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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 Miami
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Care Center | 0.1 mi | ★★★★★ | 0 | 0 |
| Ponce Health And Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Jackson Gardens Health And Rehabilitation Center | 1.2 mi | ★★★★★ | 7 | 0 |
| University Health And Rehabilitation Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Unity Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 1 | 0 |
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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.