Victoria Haven Nursing Facility

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

Have correct number of accessible exits for each story.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Administration Deficiencies

Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

Administration Deficiencies

Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.

Administration Deficiencies

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Emergency Preparedness Deficiencies

Establish procedures for tracking staff and patients during an emergency.

Emergency Preparedness Deficiencies

Establish policies and procedures for sheltering.

Emergency Preparedness Deficiencies

Establish policies and procedures for medical documentation.

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

Have correct number of accessible exits for each story.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Resident Assessment and Care Planning Deficiencies

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Construction Deficiencies

Use approved construction type or materials.

Egress Deficiencies

Have correct number of accessible exits for each story.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Egress Deficiencies

Have stairways and smokeproof enclosures used as exits that meet safety requirements.

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.