Vero Beach Care Center

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident was treated in a dignified manner for 1 of 1 sampled resident reviewed for dignity, Resident #171.

Inspectors wroteBased on interview and record review, the facility failed to obtain a completed informed consent (with date) for residents prescribed psychotropic medications for 1 of 5 sampled residents reviewed for unnecessary medication review, Resident #9.

Inspectors wroteBased on policy review, observation, interview, and record review, the facility failed to ensure the accommodation of needs for 1 of 1 sampled resident as evidenced by the lack of bedside rails for Resident #42 as per the facility's assessment and the resident's request.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment in 5 of 14 resident rooms in the [NAME] Unit affecting residents in rooms 107, 112, 115, 116, and 117.

Inspectors wroteBased on policy review, record review and interview, the facility failed to ensure that when residents are admitted to the facility that there are physician orders for the residents' immediate care for 1 of 1 sampled resident reviewed for dialysis, Resident #171.

Inspectors wroteBased on interview and record review, the facility failed to accurately code antipsychotic medication use for 1 of 5 sampled residents reviewed for unnecessary medications, Resident #82; failed to accurately code mobility status for 1 of 4 sampled residents reviewed for Activities of Daily Living, Resident #42; and failed to code the presence of a colostomy for 1 of 3 sampled residents reviewed, Resident #153. The findings Included:1. Clinical record review revealed Resident #82 was admitted to the facility on [DATE], with a readmission on [DATE], with diagnoses including Non-Alzheimer's Dementia, Anxiety Disorder, and Depression. Review of the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 12/04/25 revealed the following: Under Section N (Medications), item N0410A (Antipsychotic Medications), the resident was coded as No. [...]

Inspectors wroteBased on policy review, record review, and interview, the facility failed to ensure appropriate care and services for 6 of 44 sampled residents as evidenced by the failure to ensure hospice nursing services for Resident #29; failure to ensure timely medication administration for Residents #110, #155, and #169; and failure to follow physician ordered blood pressure parameters for Residents #1 and #41.

Inspectors wroteBased on observations interviews and record review, the facility failed to ensure residents with indwelling urinary catheters have care provided for indwelling urinary catheter for 1 of 4 sampled residents reviewed for urinary catheter or UTI (Urinary Tract Infection), Resident #14; failed to ensure indwelling urinary catheters were maintained in a manner to prevent infection for 1 of 4 sampled residents reviewed for urinary catheter or UTI, Resident #68; and failed to ensure proper peri care for 1 of 4 sampled resident reviewed for Urinary catheter/UTI, Resident #41.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure care and services for oxygen equipment for 1 of 2 sampled residents as evidenced by the failure to clean the oxygen filter for Resident #77.

Inspectors wroteBased on policy review, record review and interview, the facility failed to ensure pain management for 1 of 4 sampled residents, as evidenced by the failure to provide pain medication as per physician's orders for Resident #66.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents who were trauma survivors had triggers identified and implemented in the care plan in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 sampled resident review for Post Traumatic Stress Disorder (PTSD), Resident #7.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure adequate monitoring of side effects and behaviors for residents receiving psychotropic medications for 1 of 5 sampled residents reviewed for unnecessary medications, Residents #9.

Inspectors wroteBased on observation, interview and clinical and administrative record review, the facility failed to ensure 1 of 8 sampled residents, Resident #5, was assessed by the interdisciplinary team and established a plan of care for self-administration of medication before the resident participated in the practice.

Inspectors wroteBased on interview, clinical and administrative record review, the facility failed to honor the resident's bath preference and ensure the resident consistently received his bath preference for 1 of 8 sampled resident, Resident #4.

Inspectors wroteBased on observation, clinical and administrative record review and interview, the facility failed to ensure the residents received the necessary care and services for skin assessments and timely medication administration, as evidenced by the facility's consistent failure to respond in a timely manner fo residents who developed new skin issues and failed to ensure that residents received their prescribed medications in a timely manner, for 3 of 8 sampled residents, Residents # 1, # 4 and # 6.

Inspectors wroteBased on observation and interview, the facility failed to ensure all medications and/or supplements were not stored at the residents' bedside but were safely secured in locked compartments for 1 of 8 sampled residents, Resident #5.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide necessary care and services to prevent, identify and properly assess wounds, for 1 of 2 sampled residents reviewed for wounds (Resident #3), as evidenced by the facility failed to identify the blister or subsequent open wound to the resident's right foot, prior to surveyor intervention; the wound care nurse failed to properly assess the wound, documenting erroneous measurements and staff nurses failed to capture the wound during skin check assessment completed on 02/11/25, the day prior to the surveyor's observation.

Inspectors wroteBased on observation, record review and interview, the facility failed to provide necessary care and services to prevent and promote healing of pressure ulcers, for 2 of 2 sampled residents reviewed for pressure wounds, Resident #3 and Resident #1.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide maintenance and housekeeping services to maintain a clean, comfortable and homelike environment on 4 of 5 units and in common areas.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staffing as evidence by falls and a consistent stale urine odor on 1 of 5 units ([NAME]); lack of ADL care for 1 of 5 sampled residents (Resident #44); lack of Hospice coordination for 2 of 2 sampled residents (Resident #25 and #87); and voiced complaints by residents, families, staff, and resident council.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide food prepared, stored and served in a sanitary manner and in accordance with professional standards for food safety.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to follow infection control standards to ensure appropriate treatment for a rash outbreak on 1 of 5 units ([NAME] Unit) affecting sampled Residents #25, #30, #32, #33, #40, #42, #56, #73, #87, #93, #99, #109, #123, and #133; failed to report a rash outbreak to the Florida Department of Health (DOH); and failed to follow Enhanced Barrier Precautions (EBP) for 1 of 3 sampled residents with an indwelling urinary device for Resident #112.

Inspectors wroteSurveyor: [NAME], [NAME] Based on observations, interviews and record reviews, the facility failed to provide a safe, sanitary and comfortable environment for residents, staff and the public, in the common areas on 4 of 5 units ([NAME], Canterbury, [NAME], and [NAME]).

Inspectors wroteBased on record review and interview, the facility failed to honor resident's choice to sleep in and utilize a reclining chair for 1 of 7 reviewed for choices, Resident #138.

Inspectors wroteBased on interviews and record reviews, the facility failed to promptly act on and resolve grievances voiced by residents and the Resident Council, for 8 of the residents interviewed, including Residents #113, #85, #143, #13, #122, #27, #95, and #60. Four of 4 residents in the Resident Council meeeting voiced food concerns that included Residents #85, #113, #116 and #135. The census at the time of the survey was 146.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to ensure 1 of 1 sampled resident was free from physical restraint, Resident #128.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure accurate assessments for 2 of 42 sampled resident records reviewed, Residents #48 and #60, as evidenced for Resident #48 related to visual impairment and Resident #60 for use of antianxiety medications.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement care plans for 1 of 3 sampled residents related to behaviors reviewed for catheter, Resident #91, and the facility failed to develop and implement care plans to accurately account for vision deficit for 1 of 2 sampled residents reviewed for vision, Resident #48.

Inspectors wroteBased on record review and interview, the facility failed to revise care plans for 2 of 9 sampled residents reviewed for nutrition and or medication use, Residents #81 and #79, as evidenced by the care plan for Resident #81 lacked information related to being aggressive toward others, and the care plan for Resident #79 noted the resident had a fluid restriction order that had been discontinued.

Inspectors wroteBased on interview, the facility failed to provide services of peri care and failed to get a resident out of bed as requested for 1 of 1 sampled resident, Resident #44, reviewed for Activities of Daily Living (ADLs).

Inspectors wroteBased on observation, record review, interview, and Hospice Agreement review, the facility failed to ensure coordination of care and services for 2 of 2 sampled residents, as evidenced by the lack of orders for Hospice services and oxygen use for Resident #25; and failure to coordinate the provision of an offloading boot, lack of Certificate of Terminal Illness (CTI) paperwork, and lack of current Hospice notes for Resident #87.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to follow their fall prevention policy for initiating new interventions, updating care plans, and ensuring supervision to prevent falls for 1 of 4 sampled residents reviewed for accidents (Resident #128).

Inspectors wroteBased on observation and interview, the facility failed to secure medication storage on 2 of 5 units, as evidenced by leaving the medication and treatment carts unlocked and unattended on the [NAME] Unit, the designated memory care unit, and a random observation of non-secured ointments on the [NAME] Unit.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure complete and current medical records for 3 of 42 sampled residents (Resident #5, #26 and #81).

Inspectors wroteBased on review of the client's Arbitration agreement and interview, the facility failed to ensure the arbitration agreement is explained to the resident or representative in a manner they understand, and had a signature from the resident if they agreed to the arbitration agreement, for 2 of 3 residents reviewed for Arbitration (Resident #149 and Resident #143).

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain a functioning call system for 1 of 26 sampled residents, Resident #27; and failed to maintain a call light in a manner to be accessible to the resident for 1 of 26 sampled residents, Resident #95.

Inspectors wroteBased on observation and interview, the facility failed to ensure timely posting of nurse staffing information on 4 of 5 day during the survey (Monday 09/09/24 through Thursday 09/12/24).

Inspectors wroteBased on observation and interview, it was determined that the facility failed to provide a safe, clean comfortable homelike environment for the residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure nursing staff followed physician orders for blood pressure medication perimeters for 1 of 5 sampled residents (Resident #2) reviewed for medications; and failed to follow physician orders for a wound vac for 1 of 1 sampled resident reviewed for a wound vac (Resident #4)

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide ADL (Activities of Daily Living) care related to incontinence care, oral and personal hygiene, and personal grooming for 5 of 9 sampled residents, Residents #228, #6, #106, #16, #111. This failure in ADL assistance resulted in psychosocial harm for Resident #228.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staffing to ensure care and services to meet the needs of bathing and showering for 2 of 5 sampled residents (Resident #22 and #100); to provide incontinence care, oral and personal hygiene, and grooming for 5 of 32 sampled residents (Residents #6, #16, #106, #111, and #228); and to follow dietary recommendations and orders for obtaining weights for 3 of 5 sampled residents (Residents #111, #120, and #123). Interviews from random residents, families, and staff revealed voiced concerns of a lack of staff. Review of current residents with skin impairments revealed 7 of 9 current pressure injuries were facility acquired (Residents #33, #72, #51, #20, #64, #10, and #76). The facility utilized managers to supplement Certified Nursing Assistant (CNA) assignments on 2 of 13 days reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure interdisciplinary team (IDT) participation in care planning process for 7 of 32 sampled residents, to include food and nutrition services, activities, and therapy, as applicable involving Residents #6, #22, #41, #106, #111, #5, and #8.

Inspectors wroteBased on observation, interview and record review, the facility staff failed to speak to 4 of 32 sampled residents in a dignified manner, related to toileting and care, use of cell phones by staff during care, and staff speaking in foreign language during care, Residents #21, #22, #41, and #109.

Inspectors wroteBased on interview and record review, the facility failed to ensure baths and showers for 2 of 5 sampled residents were provided as per facility schedule and resident request, Resident #22 and #100.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide housekeeping and maintenance services to maintain a clean, comfortable and homelike environment for 3 of 5 units (Units 100, 200, and 500); and failed to maintain the residents' call lights to be accessible to the residents, for 4 of 53 sampled residents reviewed, Residents #64, #46, #4 and #85.

Inspectors wroteBased on interview and document review, the facility failed to initiate a new wound care physician order in a timely manner for 1 of 3 sampled residents reviewed for facility-acquired pressure ulcers, Resident #33.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow physician dietary orders and recommendations for obtaining weights for 3 of 5 sampled residents reviewed for nutrition, Residents #120, #111 and #123, that resulted in significant weight loss for Residents #111 and #123.

Inspectors wroteBased on record review and interview, the facility failed to respond to 1 of 1 sampled residents reviewed for vocalization of significant pain which resulted in harm, Resident #36.

Inspectors wroteBased on record review and interview, the facility failed to ensure care and services for 1 of 1 sample resident receiving dialysis, as evidenced by a lack of consistent documentation of coordination between the nursing and dialysis facility; failure to ensure documented pre and post weights to monitor for fluid overload; and failure to inform the physician and/or family of the resident's refusal of dialysis services, Resident #6.

Inspectors wroteBased on observations, interviews and record review, the facility failed to follow physician orders for 2 of 2 sampled residents with physician ordered fluid restrictions, Residents #22 and 120.