Viera Del Mar Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to be free from verbal abuse for 1 of 3 residents sampled for abuse, out of total sample of 7 residents, (#1).

Inspectors wroteBased on interview and record review, the facility failed to honor a resident's expressed wishes for Do Not Resuscitate (DNR) by not verifying those wishes were accurately documented to ensure a resident's wishes related to health care treatments and procedures at the end of life were followed for 1 of 1 resident reviewed for advance directives, out of a total sample of 57 residents, (#111). This failure contributed to resident #111 receiving cardiopulmonary resuscitation (CPR) and other invasive procedures in violation of an explicit wish for a natural and dignified death. There was likelihood resident #111 experienced severe pain, and could have suffered broken bones, organ damage, and a prolonged dying process. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain separation between contaminated and clean laundry processes with potential cross-contamination of clean linen and soiled linen.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management for 2 of 3 residents reviewed for pain management of a total sample of 57 residents, (#26, #133). Findings1. Resident #26 was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right patella, fracture of the nasal bones, rheumatoid arthritis, unspecified injury of the head and muscle weakness. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed resident #26 had a a brief interview for mental status score (BIMS) of 11 out of 15 which indicated she had moderate cognitive impairment. The MDS assessment also revealed the resident had pain occasionally. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent medication errors greater than 5 per cent for 1 of 5 residents sampled for medication administration, (#101). There were 2 errors in 32 opportunities on 1 of 5 units by 1 of 5 nurses observed, for a medication error rate of 6.25%.

Inspectors wroteBased on record review, and interview, the facility failed to ensure that a newly admitted resident received timely, consistent, and properly documented dermatologic treatment in accordance with professional standards of practice and the comprehensive, person-centered care plan for two of three residents reviewed for wound care, of a total sample of six residents, (#6, and #2). 2. Resident #2 was admitted to the facility on [DATE] for nerve pain. The Minimum Data Set Quarterly assessment dated [DATE] noted resident #2 was cognitively intact, required partial to moderate assistance with activities of daily living, and was occasionally incontinent. Review of resident #2's care plan dated 8/18/25 revealed a focus for a pressure ulcer to open area, buttocks. Interventions included to complete weekly skin checks and measure length, width, and depth, if possible. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sufficient nursing staff to provide the necessary care and services and ensure resident needs and preferences were addressed timely for 4 of 9 residents reviewed for call light response, of a total sample of 12 residents, (#7, #10, #11 and #12).

Inspectors wroteBased on interview, and record review the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected prescribed medications for 1 of 2 residents reviewed for behaviors, of a total sample of 12 residents, (#2).

Inspectors wroteBased on interview, and record review, the facility failed to ensure completion and accuracy of a Level I Preadmission Screening and Resident Review (PASARR) after a readmission for a resident diagnosed with a Serious Mental Illness (SMI), following a significant change in the resident's mental condition for 1 of 1 residents reviewed for PASARR from a total sample of 12 residents, (#2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices in accordance with infection control standards when assisting a resident with an intravenous (IV) infusion for 1 of 1 residents observed during the facility tour, from a total sample of 12 residents, (#5).

Inspectors wroteBased on interview, and record review, the facility failed to ensure implementation of policies to the extent of including thorough monitoring of previously identified areas of concern and adequately tracking performance to ensure prior improvement measures were realized and sustained.

Inspectors wroteBased on record review, and interview, the facility failed to provide a written discharge summary and list of medications for 1 of 2 residents reviewed for discharge status, of a total sample of 7 residents, (#2).

Inspectors wroteBased on interview, and record review, the facility failed to accurately document the discharge plan and disposition in the medical record; and the Activities of Daily Living (ADLs) for 1 of 2 residents reviewed for discharge status and ADLs, of a total sample of 7 residents, (#2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement appropriate interventions to include provision of adequate supervision to prevent fall with major injury for 1 of 3 residents reviewed for falls, of a total sample of 4 residents, (#1). The facility's failure to increase supervision for a resident with a history of repeated falls resulted in actual harm for resident #1.

Inspectors wroteBased on interview and record review, the facility failed to report possible neglect for 1 of 3 residents reviewed for neglect, of a total sample of 4 residents, (#1).

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate and identify possible neglect for 1 of 3 residents reviewed for neglect, of a total sample of 4 residents, (#1).

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for administration had a complete and readily accessible medical record, of a total sample of 4 residents, (#1).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the recommended restorative care to provide a splint application to prevent the potential for worsening of contractures for 1 of 2 residents reviewed for mobility/range of motion, of a total sample of 43 residents, (#85).

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain oxygen flow rates as ordered by the physician for 1 of 2 residents reviewed for respiratory care, of a total sample of 43 residents, (#75).

Inspectors wroteBased on interview and record review, the facility failed to provide care and services, according to professional standards of practice, to avoid complications of a known medical condition and prevent rehospitalization for 1 of 2 residents reviewed for hospitalization, out of a total sample of 43 residents, (#574). The facility's failure to promptly identify and treat a change in condition and failure to obtain and implement physician orders in a timely manner resulted in actual harm for resident #574. The resident suffered altered mental status and debilitating symptoms which necessitated transfer to an acute care hospital for evaluation and treatment.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, consistent with professional standards of practice, to ensure proper acquisition and administration of routine medication; and failed to appropriately dispose of discontinued medication to promote medication safety, for 1 of 2 residents reviewed for hospitalization, out of a total sample of 43 residents, (#547).

Inspectors wroteBased on observation, interview and a palatability test, the facility failed to serve palatable food at the appropriate temperature to residents in two of five halls, (300 and 600), in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to effectively communicate and implement the standards of its compliance and ethics program to promote ethical conduct, and failed to adequately enforce those requirements to deter violations and ensure the provision of quality care and promote the highest practicable well-being for resident #1 and all residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff had the appropriate competencies and skill sets required to meet residents' needs as determined by assessments and indicated in the plans of care.

Inspectors wroteBased on observation, interview, and record review, the facility's administration failed to effectively utilize its resources to provide adequate education, support and oversight for the Nursing department to ensure residents received appropriate care and services according to the plans of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedures to prohibit abuse and neglect by not identifying, reporting, and investigating incidents and events to rule out abuse and/or neglect, and ensure the safety of 2 of 12 sampled residents, (#1 & #10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement person-centered care plan interventions that accurately reflected the plans of care and promoted the highest practicable well-being for 3 of 12 sampled residents, (#1, #9, and #12).

Inspectors wroteBased on interview, and record review, the facility failed to effectively implement the discharge planning process to arrange necessary post-discharge care and services for 1 of 3 residents reviewed for discharge planning, out of a total sample of 12 residents, (#4).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide activities of daily living (ADL) care for 2 of 6 residents reviewed for ADL care out of a total sample of 12 residents, (#9 & #10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services to promote skin integrity and prevent the development of an avoidable pressure ulcer for 1 of 3 residents reviewed for pressure ulcers, out of a total sample of 12 residents, (#10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a secure environment and provide adequate supervision to prevent unauthorized, unsupervised egress from the facility and the safety of its property, for 1 of 3 residents reviewed for elopement risk, (#1); and failed to ensure a post-fall approach was implemented to prevent further injuries for 1 of 5 residents reviewed for falls, (#10), out of a total sample of 12 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and services to prevent complications related to tube feedings for 1 of 1 resident reviewed for tube feeding, out of a total sample of 12 residents (#11).

Inspectors wroteBased on interview, and record review, the facility failed to maintain a medical record that accurately documented behaviors for 1 of 3 residents reviewed for elopement risk, out of a total sample of 12 residents, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to post required nurse staffing information daily, to ensure accurate and comprehensive data was accessible to residents and/or visitors.

Inspectors wroteBased on interview and record review, the facility failed to provide pain management services in accordance with the comprehensive care plan, and the resident's goals for care and preferences for 1 of 2 residents reviewed for pain management, of a total sample of 40 residents, (#164). The facility's failure to provide pain medications as requested by the resident, per physician's orders, and consistent with the plan of care and accepted standards of practice, resulted in actual harm from prolonged periods of unmanaged pain.

Inspectors wrote2. Review of the medical record revealed resident #207 was admitted to the facility on [DATE]. She was on hospice services for congestive heart failure and had additional diagnoses including fibromyalgia, a history of cerebral infarctions with left sided weakness, asthma, and anxiety. On 7/12/22 at 5:45 PM, resident #207 was observed resting in bed. She had multiple, long, light and dark colored facial hairs located on and under her chin, above her upper lip in the shape of a mustache, and beneath her bottom lip. The facial hairs measured approximately 1/4 inch to 3/4 inch long. On 7/13/22 at 12:30 PM, resident #207's long, facial hairs were unchanged. On 7/14/22 at 11:15 AM, resident #207 was in her room with a family member. The facial hairs noted on the previous two days were still present. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food stored in the kitchen's walk-in refrigerator was appropriately labeled and dated.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan for Activities of Daily Living (ADLs) for 1 of 3 residents reviewed for ADLs of a total sample of 40 residents, (#36).

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan meeting was scheduled in a timely manner to allow the resident and/or resident representative involvement in developing comprehensive, person-centered plans of care for 2 of 3 residents reviewed for participation in care planning, of a total sample of 40 residents, (#71 & #70).

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain a physician's order for oxygen (O2) therapy for 1 of 2 residents reviewed for O2 therapy, of a total sample of 40 residents, (#165).

Inspectors wroteBased on observation, interview and record review, the facility failed to honor meal preferences for 2 of 10 residents reviewed for food out of a total sample of 40 residents, (#50 & #105).