Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
Heel Protectors Not In Place as Ordered: Two residents with orders for heel protectors while in bed were observed without the devices in place as prescribed. One resident had orders to offload heels on pillows and a care plan for bilateral heel protectors, while the other had orders and a care plan for heel protectors at all times in bed. Staff stated residents with heel protector orders were checked during rounds, and the facility policy required heel protectors to be used as ordered.
Unsafe Supervision of Resident Smoking Materials: A resident with hemiplegia, epilepsy, nicotine dependence, and moderate cognitive impairment was observed smoking in the designated area while removing a lighter from his pocket. Staff stated that residents were not permitted to keep lighters and that smoking materials were supposed to be secured at the nursing station, but the staff member did not know how the resident obtained the lighter. The resident’s assessment and care plan both required supervision while smoking and storage of cigarettes and lighters by staff.
Oxygen therapy was not administered at the ordered flow rates for two residents. One resident with respiratory diagnoses and moderate cognitive impairment was observed receiving O2 at 2.5 LPM instead of the ordered 3 LPM, and another resident with pleural effusion was observed receiving O2 at 1.5 LPM instead of the ordered 2 LPM. Staff stated oxygen flow rates and sats are verified during routine rounds, and the facility policy required verification of the physician order and flow rate.
Unsafe Storage of Biologicals and Personal Hygiene Items: Surveyors found multiple residents with personal hygiene items and air fresheners stored openly on dressers, bedside tables, shelves, and in clear plastic bags in their rooms instead of in locked storage. Staff stated this was the routine practice for storing residents’ personal hygiene products, and one RN said air fresheners were not allowed in resident rooms. The facility policy required drugs and biologicals to be stored in a safe, secure, orderly manner in locked compartments.
QAA committee failed to show an effective plan of action was implemented to correct repeated deficiencies involving F695 respiratory/tracheostomy care and suctioning and F761 label/store drugs & biologicals. Survey history showed the facility previously failed to administer oxygen as ordered for one resident and failed to properly store medications for four residents. The QAPI committee met monthly with the Administrator, DON, Medical Director, and other department heads, and the Administrator stated QAPI is used to identify and implement interventions to improve resident care and safety, but the record did not show an effective corrective plan for the repeated problem areas.
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.
Heel Protectors Not In Place as Ordered
Penalty
Summary
The facility failed to ensure positioning devices were in place as prescribed for two residents who had orders to wear heel protectors while in bed or to have heels offloaded on pillows. Resident #184 had diagnoses including malignant neoplasm of the bronchus or lung, abnormalities of gait and mobility, and a history of falling. Her physician’s orders directed staff to offload heels and bony prominences on pillows while in bed every shift, and her care plan directed staff to apply bilateral heel protectors while in bed as ordered. Resident #184 was observed asleep in bed with bilateral heel protectors noted at the foot of the bed rather than on her feet. Resident #240 had diagnoses including hypertensive heart disease, chronic kidney disease, and gout. His physician’s orders directed him to wear heel protectors while in bed at all times, and his care plan also directed staff to apply bilateral heel protectors while in bed every shift. Resident #240 was observed asleep in bed with bilateral heel protectors placed at the foot of the bed, and later was observed awake in bed with bilateral heel protectors on his feet. Staff interviews indicated that residents with heel protector orders were checked during rounds to ensure the devices were on while in bed. The facility policy titled Repositioning, revised 01/2026, stated that heel protectors were to be used and removed as ordered for all residents. Despite these orders, care plan interventions, and staff statements about checking residents during rounds, both residents were found without the heel protectors in place as prescribed during observation.
Unsafe Supervision of Resident Smoking Materials
Penalty
Summary
The facility did not maintain adequate supervision to ensure a safe environment free from accident hazards when a resident who smoked was observed removing a lighter from his pocket while seated in a wheelchair and smoking in the designated smoking area. Staff G, a CNA and Activities Attendant, stated that residents were not permitted to possess lighters and that smoking materials were supposed to be secured at the nursing station, with staff escorting residents to the smoking area and providing the cigarette and lighter as needed. Staff G did not know how the resident obtained the lighter. Resident #48 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, epilepsy, and nicotine dependence. The resident’s smoking assessment stated he smoked one to two cigarettes per day, was not able to light his own cigarette, used an apron, needed supervision, and required the facility to store lighters and cigarettes. The resident’s care plan directed that smoking materials be kept at the nursing station, that he be supervised while smoking, and that he not be allowed to keep his own cigarettes. The resident also had a BIMS score of 9, indicating moderate cognitive impairment, and required assistance with multiple activities of daily living.
Oxygen Therapy Not Administered at Ordered Flow Rates
Penalty
Summary
The facility failed to administer oxygen therapy as ordered for two residents receiving oxygen. Resident #23 had an order dated 06/10/2026 for oxygen via nasal cannula at 3 LPM continuous with humidifier every shift for shortness of breath, but observations on 06/15/2026 and 06/16/2026 showed the oxygen concentrator running at 2.5 LPM via nasal cannula. Resident #23’s clinical record listed acute upper respiratory infection and atherosclerotic heart disease of native coronary artery without angina pectoris. The resident’s quarterly MDS documented a BIMS score of 11, indicating moderate cognitive impairment, and the care plan referenced oxygen via nasal cannula at 2 LPM as needed for low oxygen saturation or shortness of breath related to respiratory insufficiency and chronic heart failure. Resident #329 had an order for oxygen via nasal cannula at 2 LPM continuous every shift for shortness of breath, but on 06/15/2026 the resident was observed asleep in bed receiving oxygen at 1.5 LPM via nasal cannula. Resident #329’s clinical record listed pleural effusion, and the quarterly MDS documented a BIMS score of 13, indicating the resident was cognitively intact, with partial assistance needed for care and oxygen therapy listed under special treatments and procedures. Staff interviews stated that residents on oxygen therapy are checked during rounds at least every two hours and that oxygen saturation and prescribed flow rates are verified during each round, and the facility policy required verification of the physician’s order and flow rate before oxygen administration.
Unsafe Storage of Biologicals and Personal Hygiene Items
Penalty
Summary
Safe and secure storage of biologicals was not maintained for five sampled residents when personal hygiene and odor-control items were found stored in resident rooms rather than in locked compartments. During observations, one tube of toothpaste and one bottle of body wash were seen on a dresser draped with a clear plastic bag in one resident’s room, while another resident’s room contained a liquid air freshener and an open bar of soap on the shelf above the handwash sink, another liquid air freshener on the bedside table, and a plugged-in liquid air freshener above the bed. In other rooms, surveyors observed three bottles of lotion, one bottle of cream, one bottle of shampoo, and one bottle of cleanser on a bedside table in a clear plastic bag; one solid air freshener on a bedside table; and one bottle of mouthwash and shampoo stored at the bedside in a clear plastic bag. Staff interviews showed that personal hygiene products were routinely stored in clear plastic bags in resident rooms or closets for safety, and multiple staff members described this as the facility’s practice. One RN stated that personal hygiene products are stored in a plastic bag in a dresser, while other CNAs and RNs stated that these items are stored in clear plastic bags inside the closet for safety. A charge nurse and another RN also stated that residents’ personal hygiene products must be stored in clear plastic bags in the closet for the safety of residents and staff. One RN further stated that residents are not allowed to have air fresheners in their rooms and that staff should remove them if found. The facility policy titled Storage of Medications/Biologicals stated that drugs and biologicals are to be stored in a safe, secure, and orderly manner in locked compartments under proper temperature, light, and humidity controls.
QAA Committee Failed to Address Repeated Deficiencies
Penalty
Summary
The facility's QAA committee failed to demonstrate an effective plan of action was implemented to correct repeated quality deficiencies related to F695 Respiratory/Tracheostomy care and Suctioning and F761 Label/Store Drugs & Biologicals. Survey history showed that during the December 09, 2024 through December 12, 2024 recertification survey, F695 was cited because the facility failed to administer oxygen as ordered for one resident, and F761 was cited because the facility failed to properly store medications for four residents. Review of the facility's QAPI policy showed the facility was required to maintain a standing QAPI committee overseen by the Administrator. QAPI committee sign-in sheets documented monthly meetings on 04/01/2026, 05/06/2026, and 06/03/2026, with attendance by the Administrator, Medical Director, DON, Infection Control Preventionist, Risk Manager, and multiple department heads. During interview, the Administrator stated the committee meets every month and that QAPI is intended to identify and implement interventions to improve resident care and safety, but the record did not show an effective plan of action had been implemented to correct the repeated deficiencies in the cited problem areas.
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 | ★★★★★ | 3 | 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 | ★★★★★ | 0 | 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 August 2026) and official state health department websites.