Veranda Rehabilitation and Healthcare

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 6 residents (Resident #1 and Resident #2) reviewed for medical records. 1. The facility failed to ensure RN B, LVN C, and LVN D documented Resident #1's vital signs accurately on her MAR on multiple occasions from 06/19/26 to 06/24/26.2. The facility failed to ensure RN B, LVN C, and LVN D documented Resident #2's Skilled Assessments accurately and timely on multiple occasions from 07/06/26 to 07/26/26. This failure could place residents at risk of errors in care and treatment.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 3 residents (Resident #1) reviewed for developing and implementing abuse and neglect policies and procedures. 1) RN D did not report Resident#1's injury of unknown source to the facility management. 2) The facility did not report an incident of possible neglect to the state agency within the given time frame. These failures could place all residents residing in the facility at risk of abuse/neglect. Based on interviews and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 3 residents (Resident #1) reviewed for developing and implementing abuse and neglect policies and procedures. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegations of abuse, neglect, exploitation, or mistreatment, including injury of unknown origin, were reported immediately, but not later than 2 hours in accordance with State law through established procedures for one (Resident #1) of 3 residents reviewed for abuse. The facility failed to ensure Resident #1's Injury of Unknown origin, discovered on 3/24/26, was immediately, but no later than two hours, reported to the State Survey Agency. These failures could place residents at risk of delays in the investigations of incidents of abuse and neglect.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered- care plan, and the resident's choices for 1 (Resident #1) of 3 residents reviewed for quality of care. The facility failed to recognize x-ray results done on 3/24/2026 that reflected There are acute appearing mildly displaced fractures of the right 4th and 5th ribs anterolaterally. Correlate with timing of trauma and pain for age of fractures. This failure could place residents at risk of delay in care, worsening of health conditions, adverse reactions, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 2 residents (Resident #1) reviewed for intravenous fluids. The facility failed to ensure Resident #1's intravenous medication bag was labeled with Resident #1's name, dose, frequency, and route. This failure placed the residents at risk for infections, wrong dose, and clinical monitoring of doses.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for medical records accuracy. The facility failed to ensure Resident #1's January 2026 MAR accurately documented when her physician ordered Alprazolam was not given. This failure could place residents at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility to ensure when not in use, medication carts were stored and secured in a designated area for 1 of 4 carts (1 and 2 hallways) medication carts reviewed for drug security. The facility failed to ensure that the nurses medication cart for 1 and 2 hallways was secured by a lock when it was left unattended by RN A. The failure could place residents at risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 kitchen reviewed for environmental conditions. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from misappropriation of property and exploitation for 1 of 3 (Resident #39) reviewed for misappropriation and exploitation, in that: The facility failed to ensure Resident #39 was free from exploitation. On 03/10/25, the facility learned that the former ABOM had accessed R Resident #39's bank account information and withdrew funds without his knowledge or consent on 18 different occasions. As a result, Resident #39 lost $4671.22 from his checking account. This failure could affect residents and their responsible party by preventing them from having access to their funds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 8 residents (Resident #'s 44, Resident #30) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #44 ' s care plan included his ADL self-performance deficit for eating when Resident #44 needed substantial/maximal assistance and needed to be fed. 2. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #30's smoking. These deficient practices could place residents at risk of not receiving appropriate treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 of 4 residents (Resident #20) reviewed for infection control. The facility failed to ensure the dressing on Resident #20's peripheral intravenous line (a short flexible tube inserted into a vein to administer fluids and medications) was dated and initialed. The failures could affect residents by placing them at risk for infections.

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (Resident #1 and Resident #2) of six residents reviewed for behavioral health services. The facility failed to follow-up to ensure Resident #1 and Resident #2 received a psychiatric consultation after an order was received from the MD on 05/30/24. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #3) of six residents. The facility failed to ensure that Resident #3 received his eye drops to his left eye as prescribed on the physician's prescription orders dated 2/26/25. Resident #3 received 1 drop twice a day instead of 1 drop three times a day to his left eye. This facility's failure placed residents receiving medications at risk for drug diversion, drug overdose, and decrease efficacy of medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete, accurate, readily accessible, and systematically organized for 1 (Resident #11) of 24 residents reviewed for Advance Directives. The facility failed to have complete, accurate and readily accessible records to identify Resident #11's code status. Resident #11's medical record indicated Resident #11 code status was DNR, but the OOH-DNR form was not in Resident #11's medical record. This failure could affect residents who have implemented Advance Directives and established their choice to not be resuscitated at risk of receiving CPR against their wishes.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #78 and Resident #241) of five residents reviewed for infection control in that: 1. LVN A failed to properly disinfect equipment after providing wound care for Resident #78. 2. LVN A failed to wear appropriate PPE while providing device care for Resident #241. 3. LVN A failed to change all required items during device dressing care for Resident #241. These deficient practices could place residents at risk of infection, transmission of communicable diseases, and a decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one resident of 3 residents (Resident#1) reviewed for supervision. 1. The facility failed to ensure Resident #1 received adequate supervision when Resident #1 eloped from the facility on 12/06/23. Resident #1 was found by Driver A on 12/06/23 approximately 0.2 miles from facility near a highway. 2. The facility failed to implement interventions to prevent Resident #1's elopement from the facility. The non-compliance was identified as PNC. The IJ began on 12/06/23 and ended on 12/07/23. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of injury or death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 7 residents (Resident #2) reviewed for accommodation of needs. The facility staff did not provide Resident #2 with a call light that was within reach. This failure could place residents who utilized call lights at risk for not having his/her needs met.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving neglect, including injuries of unknown source were reported immediately, but not later than 2 hour if the alleged violation resulted in serious bodily injury, to the administrator of the facility and to the State Survey Agency for 1 of 4 residents (Resident #22) reviewed for reporting injuries of unknown origin. The facility did not report within 2 hours when Resident #22 was found on the floor with purple discoloration and a hematoma. Resident #22 was sent to the emergency room, where a CT scan revealed a subarachnoid hemorrhage. This failure could place residents at risk for undetected abuse, neglect and/or decline in feelings of safety and well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident's environment remained as free of accident hazards as possible for 1 in 8 residents (Resident # 51) Resident #51 was found to have a multiple blade razor in his room on top of his chest of drawers. This failure could place residents at risk for injury or harm.