Victoria Post Acute Care
Inspection Findings
F-Tag F0684
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to check a resident's blood sugar for a resident with diabetes (high blood sugar) for one of two sampled residents reviewed for diabetes management (Resident 1). This failure had the potential to place Resident 1 at risk for poor diabetes management.Findings: On 8/21/25, the Department received a complaint related to Resident 1's untimely and missed blood sugar check at the facility. Resident 1 was admitted to the facility on [DATE REDACTED], with diagnoses which included diabetes and on long term use of insulin (injectable medication for diabetes), per the facility's admission Record. Resident 1's history and physical, dated 7/29/25 indicated Resident 1 had the capacity to understand and competent to make complex medical decisions. On 9/4/25 at 1:13 P.M., a joint interview with the Director of Nursing (DON) and a review of Resident 1's clinical record was conducted. The DON stated Resident 1 was alert and oriented and knew what was going on. The DON stated Resident 1's blood sugar was checked four times a day (before meals and at bedtime). The DON stated on 7/30/25, Resident 1's blood sugar was documented as checked at 9:52 A.M. The DON stated the facility usually served breakfast around 8 A.M.
The DON also stated on 7/30/25, there was no blood sugar check documented for Resident 1 before lunch.
The DON stated Licensed Nurse (LN) 2 was the LN who worked that day. The DON stated there was no blood sugar check and no insulin coverage at lunch time for Resident 1. The DON stated there was no documentation Resident 1 refused blood sugar check. The DON stated the expectation was for the LNs to follow the physician's order and document in the resident's clinical record. The DON stated blood sugar monitoring was important so the facility could implement appropriate interventions if high or low. On 9/4/25 at 1:39 P.M., a telephone call was made to interview LN 2, but unable to talk to LN 2. A policy for diabetes management was requested but per DON, the facility had a policy for Physician Orders. A review of the facility's undated policy titled, Physician Orders - Administration of Medications/Treatments, indicated, It is
the policy of this Facility, medication and treatment shall be administered by Licensed Nurse as prescribed by the resident's physician .4. Medication and treatment administration will be recorded on the resident's administration record (i.e. MAR/TAR/DAR).
Residents Affected - Few
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
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
VICTORIA POST ACUTE CARE in EL CAJON, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL CAJON, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from VICTORIA POST ACUTE CARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.