Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Victoria Crossing Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including post-amputation orthopedic aftercare, osteomyelitis, COPD, and muscle weakness, was discharged home with a PT note indicating home health was recommended, but without documentation that these services were arranged or that required discharge planning steps were completed. The resident filed an appeal with DCF, asserting they were being erroneously discharged, yet the EMR contained no documentation of the appeal, no AHCA discharge/transfer form, and no discharge summary. The SSD confirmed the absence of these records, and the NHA acknowledged that Social Services should document discharge assessments and that residents who appeal should not be discharged until an appeal decision is made, but stated that coverage gaps in Social Services led to discharge processes not being done correctly.
A resident admitted with post-amputation orthopedic aftercare, osteomyelitis of the left ankle and foot, COPD, and muscle weakness was discharged without required discharge documentation. Record review showed no AHCA discharge/transfer form, no documented discharge notifications or reason for discharge, no discharge summary, and no post-discharge plan of care, despite facility policy requiring these elements. The SSD confirmed the absence of appeal and discharge documentation, and the NHA acknowledged that social services staff responsible for discharge planning and resident notification had not completed the required assessments and notes.
A resident who was always incontinent of bowel and bladder, had multiple comorbidities, and was on diuretic therapy reported remaining wet for extended periods and typically not being changed until late morning. Surveyors observed the resident in bed with a noticeable urine odor in the room and later noted excoriation in the groin area, although the brief was dry at that moment. Staff stated that CNAs should round every 2–3 hours, check heavy wetters more often, and document toileting and incontinence care as it occurs, but a 14‑day review of CNA documentation showed multiple missing and inconsistent entries across shifts. The unit manager and DON confirmed that toileting episodes were not consistently documented and acknowledged that undocumented care is considered not done.
The facility did not ensure that staff were trained and available on all shifts to manually transfer power to the standby generator, which is necessary to maintain safe indoor temperatures during a power outage. The lack of training and absence of a designated individual to perform this task resulted in noncompliance with emergency environmental control requirements.
A facility failed to ensure proper infection control practices, including PPE use and hand hygiene, on one unit. A nurse did not perform hand hygiene after administering medication, and a visitor and staff member were observed in a resident's room with contact precautions without PPE. Confusion among staff about PPE use for a resident with a UTI and ESBL resistance was noted. The order for contact precautions was delayed, and the facility's infection control policies were not followed.
The facility failed to notify the family and physician of a change in condition for two residents. One resident, with multiple diagnoses, was confused and called family for help, leading them to call 911. Despite the family's request, the night nurse refused to send the resident to the hospital, and there was no documentation of a change in condition or physician notification. The second resident had a leg wound, but there was no documentation of a change in condition or notification to the physician and family.
A resident with a history of diabetes and bilateral amputations was found with untreated wounds, including a necrotic eschar on the right stump. The resident reported pain and lack of care, and it was confirmed that the wound care team was not involved, and no orders were in place. The facility lacked documentation of skin sweeps, physician, and family notifications, and did not have a Wound Care or Skin Assessment Policy.
A facility failed to provide dialysis care per physician orders for a resident dependent on renal dialysis. The resident's care plan required site assessments, bleeding checks, and vital sign monitoring, but documentation was incomplete on several occasions. Interviews with an LPN and the DON confirmed the need for proper documentation, which was not consistently done, and a dialysis policy was not provided when requested.
Failure to Honor Discharge Appeal and Document Discharge Planning
Penalty
Summary
Surveyors identified that the facility failed to allow a resident to remain in the facility during a pending discharge appeal. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, other acute osteomyelitis of the left ankle and foot, COPD, and muscle weakness, and had a care plan goal to return home with family once able to verbalize needed assistance and required services post-discharge. The care plan directed Social Services to encourage the resident to discuss concerns impeding discharge, establish a pre-discharge plan, and arrange community resources to support independence after discharge. A PT discharge summary covering the stay indicated the plan was for the resident to discharge home at the highest practical level with recommended home health services, but the summary did not document whether those home health services were actually arranged prior to discharge. A DCF appeal hearing form showed that an appeal of the discharge was filed based on the resident’s belief that they were being erroneously discharged from the facility. The resident’s electronic medical record contained no documentation that the resident or representative had filed an appeal, no notes explaining why the resident might not have been ready for discharge, no AHCA discharge/transfer form, and no documented discharge summary. The SSD, newly employed and unfamiliar with the case, confirmed the absence of any appeal-related documentation and required discharge forms in the record. The NHA stated that Social Services is responsible for discussing discharges, completing assessments, and documenting discharge notes, and acknowledged that if a resident files an appeal, they should not be discharged until after the appeal decision, but also acknowledged that coverage gaps in Social Services led to discharge processes not being completed correctly. The facility’s discharge planning policy required a process focused on resident discharge goals, support system, and transition timing to ensure a smooth process, which was not reflected in the documentation for this resident.
Failure to Document Required Discharge Notifications and Summary
Penalty
Summary
The facility failed to complete and document required discharge and transfer notifications, including the reason for discharge, for one resident. The resident was admitted with diagnoses including orthopedic aftercare following surgical amputation, other acute osteomyelitis of the left ankle and foot, COPD, and muscle weakness, and was later discharged. Review of the electronic medical record showed no documentation of the required discharge elements per facility policy, including the AHCA discharge/transfer form, discharge notifications, or the reason for discharge. There was also no documented discharge summary or evidence of a post-discharge plan of care. During interviews, the Social Services Director stated they had only worked at the facility for one week, did not know the resident, and were unaware of any discharge appeal. After reviewing the record, the Social Services Director confirmed there was no documentation of an appeal, no AHCA discharge/transfer form, and no discharge summary. The Nursing Home Administrator stated that social services is responsible for discussing discharge with residents, conducting an assessment, documenting notes related to discharge, notifying residents at least two days before discharge, and documenting a meeting about the discharge plan. The Nursing Home Administrator acknowledged that there was nothing in the record related to the discharge and explained that the facility did not have a dedicated social services staff member at the time and that coverage staff were not completing the required discharge documentation correctly. Review of the facility’s Discharge Planning policy confirmed that a discharge summary and post-discharge plan of care are required but were not present in this case.
Failure to Provide and Document Timely Incontinence and Toileting Care
Penalty
Summary
Surveyors identified a deficiency in the facility’s provision of toileting and incontinence care for a resident who was always incontinent of bowel and bladder and required assistance with turning, repositioning, personal hygiene, and toileting. The resident, who had diagnoses including arthritis, COPD, and heart failure and was on diuretic therapy for edema, reported being wet and not having been changed since 5:00 a.m., and stated that staff typically did not change them until they were dressed around 11:00 a.m. During a morning observation, the resident was found lying in bed and reported being wet, and on another morning observation, there was a noticeable urine odor in the resident’s room while the resident was in bed eating breakfast. The resident reported having open areas in the groin and using a medicated barrier cream they had purchased, while the facility provided another type of barrier product. During an observed assessment of the groin area with an LPN, the resident’s incontinence brief appeared dry at that time, but the groin area outside the brief was excoriated, and the LPN then provided incontinence care. Staff interviews indicated that CNAs were expected to receive report from the prior shift, round on residents in the morning to ensure they were clean, and check residents for incontinence every 2–3 hours, with more frequent checks for heavy wetters. Staff also stated that if a resident refused to be changed, they were to re-approach and involve additional staff and a nurse if refusals continued, and that this resident was able to make needs known. Review of the CNA documentation for bladder function over a 14‑day lookback period showed multiple gaps and inconsistencies in recorded episodes of continence and incontinence across all three shifts. There were instances where several episodes of incontinence were documented within short time frames, followed by long periods with no documentation for an entire shift or more than 14–24 hours between entries. The unit manager and DON both stated that CNAs were supposed to document toileting and incontinence care as it occurred, that staff should be rounding every two hours and per resident request, and confirmed that toileting episodes were not consistently documented. The DON acknowledged that if care was not documented, it was considered not done, highlighting missing documentation for toileting and incontinence care for this resident.
Failure to Ensure Trained Staff for Manual Emergency Power Transfer
Penalty
Summary
The facility failed to ensure that emergency power could be transferred to maintain safe indoor temperatures in the event of a loss of primary electrical power. During a review of the Comprehensive Emergency Management Plan (CEMP) and the generator/cooling plan, it was found that the facility only had a manual option to transfer power to the standby generator, which is responsible for supplying emergency power to the air conditioning system in designated cool zones. There was no evidence provided that an on-site and trained individual was available during all shifts to perform the manual transfer of power to the standby generator. This gap in staffing and training meant that, in the event of a power outage, there was no assurance that the generator could be activated promptly to maintain required temperatures for resident safety and comfort. Interviews with the Administrator and the Human Resource officer confirmed that staff had not been trained to perform the manual transfer of power. Additionally, it was stated that this training was not included as part of the emergency plan for new employee orientation. This lack of training and preparedness directly contributed to the facility's inability to meet the licensure requirement for emergency environmental control.
Infection Control Deficiency in PPE Use and Hand Hygiene
Penalty
Summary
The facility failed to ensure proper infection control practices on one of its units, specifically regarding the use of personal protective equipment (PPE), the timeliness of contact precaution orders, and hand hygiene. During an observation, a registered nurse did not perform hand hygiene after administering medication to a resident and before touching the medication cart. Additionally, a visitor and an unknown staff member were observed in a resident's room, which had a Contact Precaution sign, without wearing any PPE. Interviews revealed confusion among staff regarding the necessity of PPE when entering the room of a resident on contact precautions for a urinary tract infection (UTI) with extended spectrum beta lactamase (ESBL) resistance. The resident in question was admitted with diagnoses including a UTI, ESBL resistance, and was a carrier of methicillin-resistant Staphylococcus aureus. Lab results confirmed the presence of Escherichia coli and ESBL in the urine, which were reported to the facility, but the order for Isolation Contact Precautions was not entered until a day later. The Director of Nursing confirmed that staff should perform hand hygiene immediately upon exiting a resident's room and that PPE should be worn anytime someone enters a room with contact precautions. The facility's policies on infection control and isolation protocols were not adhered to, contributing to the deficiency.
Failure to Notify Family and Physician of Change in Condition
Penalty
Summary
The facility failed to notify the family and physician of a change in condition for two residents. For the first resident, who had multiple diagnoses including acute respiratory failure and Alzheimer's disease, there was a lack of documentation and communication regarding his condition. The resident was confused and repeatedly called family members for help, prompting them to call 911. Despite the family's request to send the resident to the hospital, the night shift nurse refused, stating the resident was fine. The resident later refused to be transferred by EMTs, and there was no documentation of a change in condition, physician notification, or interventions to address his needs. The Assistant Director of Nursing later noted a positive urine culture for a UTI, but there was no documentation of care or monitoring prior to the resident's death. Interviews with staff revealed a lack of documentation and communication with the physician and family. The Director of Nursing confirmed the absence of documentation regarding family notification and physician contact. The Medical Director and ARNP also did not recall being informed of the family's concerns or the resident's refusal of treatment. For the second resident, who had a history of diabetes and end-stage renal disease, the facility failed to notify the family and physician of a leg wound. The resident's skin evaluation revealed a dark area with a small opening on the right stump, but there was no documentation of a change in condition or notification to the physician and family. Interviews with staff confirmed that a change in condition should have been completed and the provider notified, but this was not done.
Failure to Provide Wound Care and Assessments
Penalty
Summary
The facility failed to provide appropriate wound assessments and care for a resident with wounds, as observed during a survey. The resident, who had a history of type 2 diabetes mellitus, end-stage renal disease, and bilateral below-knee amputations, was found to have a scab with small spots of blood on the left knee and a large area of necrotic eschar with small open areas of slough on the right lower extremity stump. The resident complained of pain and reported that she had informed the nurses about her need for wound care, but no action was taken. Upon review, it was confirmed that the wound care team was not following the resident, and there were no wound care orders in place. Further investigation revealed that the facility lacked documentation of skin sweeps, physician notification, and family notification regarding the resident's condition. The resident's care plan included interventions for skin integrity and pressure injury prevention, but these were not followed. The Director of Nursing acknowledged that the resident should have had wound care orders and assessments, and the Nursing Home Administrator admitted that the facility did not have a Wound Care Policy or a Skin Assessment Policy in place.
Failure to Provide Proper Dialysis Care and Documentation
Penalty
Summary
The facility failed to provide Hemodialysis (HD) care per physician orders for a resident dependent on renal dialysis. The resident was admitted with a diagnosis of renal failure requiring dialysis. Physician orders required the assessment of the dialysis site for infection every shift, checking for bleeding, and monitoring vital signs. The care plan also included changing the dressing daily and ensuring the resident attended scheduled dialysis appointments. However, the review of dialysis communication forms revealed incomplete pre and post-dialysis care documentation on multiple occasions, indicating a failure to adhere to the prescribed care protocols. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that pre and post-dialysis care should be documented on the dialysis form, which was not consistently done. The LPN stated that pre-dialysis care involves checking vitals and managing medications, while post-dialysis care includes monitoring the site and documenting as ordered. Despite these requirements, the facility did not provide a dialysis policy when requested, further highlighting the deficiency in ensuring proper dialysis care and documentation for the resident.
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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 Brandon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Oakfield | 1.1 mi | — | 3 | 0 |
| Aviata At Central Park | 1.2 mi | — | 3 | 0 |
| Hawthorne Center For Rehabilitation And Healing Of | 1.6 mi | — | 0 | 0 |
| Elon Manor Nursing And Rehabilitation Center | 9.4 mi | — | 1 | 0 |
| Whispering Oaks | 9.5 mi | — | 11 | 0 |
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