Venice Health and Rehabilitation Center

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to have menus that were prepared in advance and reviewed by a dietitian or other clinically qualified nutrition professional for nutritional adequacy.

Inspectors wroteBased on observation and staff interviews, the facility failed to store food in accordance with professional standards for food service safety.

Inspectors wroteBased on observations, review of facility's policy and procedure, residents and staff interviews, the facility failed to store residents' personal care items in a sanitary manner in 7 (Rooms 501, 508, 503, 504, 506, 507, and 404) of 20 rooms observed on the 500 and 400 hallways. The facility failed to provide maintenance services to ensure the necessary repair of furniture for 2 (Residents #48 and #25) of 31 residents observed. The findings Included:Review of the facility's policy for Personal Items last reviewed 1/5/2020 revealed: The facility has designed and implemented processes which strive to ensure safekeeping of resident/patient personal items. The staff is oriented to the facility's efforts to protect the property, practice infection control, and implement safety measures upon hire; [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to provide the advanced Beneficiary Notice to 1 (Resident #21) of 3 residents reviewed for potential financial liability for services that may not be covered by Medicare.

Inspectors wroteBased on record review and staff interviews, the facility failed to protect residents' right to be free from neglect by failing to ensure staff consistently provide safe nursing care to prevent avoidable accidents and serious physical harm for 1 (Resident #1) of 3 dependent residents reviewed. Resident #1 had a history of cerebral infarction (stroke) with resultant hemiplegia (paralysis) of his right dominant side and was dependent on the assistance of 2 staff for bed mobility. On 6/19/25 the Certified Nurse Assistant (CNA) chose to not follow safety precautions of 2 staff assistance listed on the care plan to provide incontinent care, causing Resident #1 to fall out of bed. Resident #1 sustained a serious head injury from the avoidable fall, requiring an emergency transfer to an acute care hospital for evaluation and treatment. [...]

Inspectors wroteBased on record review, review of facility's policy and procedure, and staff interviews, the facility failed to ensure effective processes were in place to protect 1 (Resident #1) of 3 residents reviewed from avoidable fall and fall related major injury. Resident #1 had a history of cerebral infarction (stroke) with resultant hemiplegia (paralysis) of his right dominant side and was dependent on the assistance of 2 staff for bed mobility. On 6/19/25 the Certified Nurse Assistant (CNA) chose to not follow safety precautions of 2 staff assistance listed on the care plan to provide incontinent care, causing Resident #1 to fall out of bed. Resident #1 sustained a serious head injury from the avoidable fall, requiring an emergency transfer to an acute care hospital for evaluation and treatment. [...]

Inspectors wroteBased on observation, facility policy and procedures review, record review and staff interviews, the facility failed to maintain urinary catheters in a safe and sanitary manner for 3(Residents #44, #51 and #65) of 5 residents reviewed with indwelling urinary catheters.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the accuracy of a Pre-admission Screening and Resident Review by failing to make the necessary corrections for 2 (Residents #14 and Resident #41) of 5 residents with a new diagnosis of mental illness.

Inspectors wroteBased on observation, facility policy and procedures review, record review and staff interviews, the facility failed to store nebulizer inhalation equipment and bilevel positive air pressure (BiPAP) machine in a sanitary manner for 1(Resident #21) of 1 resident reviewed for respiratory care.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure ongoing communication and collaboration with the dialysis center related to assessment of the resident before, during and after each dialysis treatment for 1 (Resident #84) of 1 resident reviewed for dialysis.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain the kitchen in a clean and sanitary manner to prevent possible contamination of food on the tray line from dirty air vents. The lack of sanitation in the kitchen has a potential to affect all residents who consume an oral diet.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure completion of the admission Minimum Data Sat (MDS) assessment within 14 days from date of admission or the annual MDS assessment within 366 days of the assessment reference date (ARD) of the last annual MDS assessment as required by regulation for 5 (Resident #14, #16, #343, #345 and #346) of 20 residents sampled. This has potential to delay assessment and formulation of the plan of care.

Inspectors wroteBased on interview and record review, the facility failed to complete the Quarterly Minimum Data Set (MDS) Assessment within 14 days of the Assessment Reference Date (ARD) as required by regulation for 5 (Residents #85, #17, #13, #12, and #30) of 20 residents reviewed for quarterly assessments.

Inspectors wroteBased on record review and interview the facility failed to ensure Minimum Data Set (MDS) tracking records were submitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion of the event for 6 residents (Resident #347, #72, #350, #351, #20 and #349) of 10 reviewed for timely submission.

Inspectors wroteBased on observation, record review, Resident and staff interview, the facility failed to identify, assess, address, and monitor individual underlying causes and contributing factors for decline in 4 areas in functional mobility for 1 Resident (Resident #17) who had a significant change in condition of 2 Resident reviewed. On 4/25/22 at 12:15 p.m. Resident # 17 was observed in bed with staff assisting with feeding. On 4/25/22 at 1:36 p.m., Certified Nursing Assistant (CNA), Staff G, said Resident # 17 was now dependent on staff for eating. Resident #17 used to be able to feed herself. Staff G said Resident #17 used to be able to transfer with minimal assistance but now required a mechanical lift for transfers. On 4/26/22 at 8:09 a.m., Licensed Practical Nurse (LPN) Staff H said Resident # 17 was requiring more assistance with activities of daily living (ADL) from staff. [...]

Inspectors wroteBased on observation, review of facility policies and procedures, review of clinical records and resident and staff interviews, the facility failed to provide appropriate services and interventions for the management of contractures for 1(Resident #63) of 2 residents reviewed with limited range of motion.

Inspectors wroteBased on observation, review of facility's policy, and staff interview, the facility failed to maintained medications in locked compartment when not under direct observation for 1 (400 hall) of 6 medication carts observed.

Inspectors wroteBased on observation, record review, resident and staff interview, the facility failed to provide Therapy Services as ordered by Physician for 1 (Resident #251) of 5 Residents reviewed for Rehabilitation Services.

Inspectors wroteBased on observation, review of the facility policy and procedure, resident and staff interview the facility failed to maintain a clean, and sanitary environment by failure to store resident personal care items in a sanitary manner for 2 (Resident #16 and #31) of 25 rooms observed and failed to ensure shared resident care equipment is routinely cleaned.