Victoria Healthcare And Rehabilitation Center
VICTORIA HEALTHCARE AND REHABILITATION CENTER in COSTA MESA, CA — inspection on September 4, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of the facility's P&P titled Recognition and Management of Pain revised 7/2017 showed the medications administered to the resident will be documented on the MAR.
Medical record review for Resident 1 was initiated on 9/3/25. Resident 1 was readmitted to the facility on [DATE], and discharged to the community on 8/23/25.
Review of Resident 1's Order Summary Report showed a physician's order dated 8/18/25, for the following:- for hydrocodone/APAP 5-325 mg tablets, give one tablet by mouth every four hours as needed for pain level 4-7 (in a pain scale of 0-10, 0 = no pain to 10 = severe pain); and- for hydrocodone/APAP 5-325 mg tablets, give two tablets by mouth every four hours as needed for pain level 8-10, do not take more than eight tablets in 24 hours, APAP not to exceed 4,000 mg per day. a.
Review of Resident 1's Tab Narcotic and Hypnotic Record for hydrocodone/APAP 5-325 mg tablets showed on 8/20/25 at 0132 hours, one tablet of hydrocodone/APAP 5-325 mg was removed from the supply.
Review of Resident 1's MAR for August 2025 showed on 8/20/25 at 0132 hours, the nurse electronically signed the administration of two hydrocodone/APAP 5-325 mg tablets to Resident 1 for a pain level of 7. On 9/4/25 at 1021 hours, an interview and concurrent record review was conducted with the DON.
The DON stated the nurse accidentally signed the MAR and showed two tablets were administered instead of the one tablet removed from the controlled supply. b.
Review of Resident 1's Tab Narcotic and Hypnotic Record for hydrocodone/APAP 5-325 mg tablets showed on 8/22/25 at 1930 hours, one tablet of hydrocodone/APAP 5-325 mg was removed from the supply.
Review of Resident 1's MAR for August 2025 failed to show documentation if the hydrocodone/APAP controlled medication removed from the supply on 8/22/25 at 1930 hours was administered to Resident 1. On 9/4/25 at 1021 hours, an interview and concurrent record review was conducted with the DON.
The DON verified the one tablet of hydrocodone/APAP 5-325 mg removed from the controlled supply on 8/22/25 at 1930, was not documented in Resident 1's MAR.
The DON stated the administration of the controlled medication should have been documented.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
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