Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Viera Del Mar Health And Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Honor DNR Status and Code Order Changed Without Consent: A resident with severe cognitive impairment and multiple serious diagnoses was admitted with a DNR order on the hospital transfer form, and the admitting nurse documented that the DNR wishes were verified with the resident and family. The next day, a physician order for full code was entered without resident or family consent because staff believed a goldenrod DNRO form was required. When the resident was later found unresponsive, staff initiated CPR and EMS continued resuscitation, including intubation and IO access, despite the son stating he never authorized a change from DNR.
Laundry room processes failed to keep clean and soiled linen separated. During a tour with the Housekeeping Manager, IP, and Regional Housekeeping Director, three washers were observed in the dirty linen area with soiled linen bins placed very close to the washers and no defined separation between areas. The Housekeeping Manager and Regional Director stated they were not aware clean and soiled linen needed to be separated and acknowledged the setup could cause possible cross contamination of linen.
Delayed pain medication administration: Two residents with physician-ordered opioid analgesics for pain did not receive their medications on time. One resident with fractures, RA, and moderate cognitive impairment reported waiting since early morning for pain medication and had multiple late hydrocodone-acetaminophen doses without documented reasons. Another cognitively intact resident with post-joint replacement pain and OA reported repeated delays, including missed or late oxycodone-acetaminophen doses and an emergency order dose later that night. The facility’s medication administration standards required meds to be given within 1 hour of the scheduled time and any delay to be documented.
Medication administration errors exceeded the 5% threshold for a resident, with 2 errors in 32 opportunities for a 6.25% error rate. During observation, an LPN removed several meds for the resident, but Potassium Chloride 20 meq and Sertraline 50 mg were marked as given on the MAR even though they were not administered during the med pass.
The facility failed to consistently provide and document ordered wound and dermatologic treatments for two residents. One resident with a pressure ulcer and lower leg abrasions had physician orders for specific cleansing and dressings, as well as Dakins and zinc oxide applications, yet the TAR showed multiple missed treatments across several shifts. Another resident with tinea pedis had a dermatology order for daily Ketoconazole cream to both feet, but interviews with multiple LPNs revealed conflicting accounts about application, an unopened tube of cream, lack of refills, and uncertainty about prior use, while family reported the resident did not receive the cream for several days after admission.
Multiple residents experienced prolonged call light response times and unmet care needs due to insufficient nursing staff. Residents with recent hospitalizations, pain management needs, and respiratory conditions reported significant delays in receiving assistance, while staff described heavy workloads and frequent understaffing. Resident Council discussions and facility records confirmed ongoing concerns about staffing shortages and their impact on timely care.
A resident with multiple psychiatric and neurological diagnoses was administered several classes of medications, including antidepressants, anticonvulsants, antipsychotics, antibiotics, and opioids. The MDS assessment failed to accurately document all medication classes received during the lookback period, omitting antipsychotic, antidepressant, and opioid medications, despite facility policy requiring comprehensive and accurate assessments.
A resident with a history of SMI and multiple psychiatric diagnoses experienced significant behavioral changes and new mental health diagnoses after hospital readmission. Despite ongoing psychiatric symptoms and interventions, the facility did not complete or update the required Level I PASARR, and key documentation was left incomplete. Staff interviews confirmed the oversight, and there was no policy in place to clarify responsibility for PASARR updates.
An LPN failed to remove gloves and perform hand hygiene when exiting and reentering a resident's room during the setup of an IV iron infusion. The LPN handled equipment and moved a trash can while wearing the same gloves, contrary to infection control protocols. The DON confirmed that staff are expected to remove gloves and perform hand hygiene before leaving a resident's room, and that all staff receive related education.
The facility experienced repeated deficiencies in the accuracy of medical record documentation due to insufficient monitoring and oversight by the QAPI team. Despite providing education to nursing staff and planning audits, the same issue was cited in multiple surveys, and the Administrator was not aware of previous deficiencies, indicating a lack of effective tracking and follow-through on corrective actions.
A resident with multiple medical conditions was discharged without a complete written discharge summary or medication list, and key sections of the discharge documentation were left blank. The resident's designated representative was not notified in advance, and there was no evidence that discharge instructions or medications were provided. Staff interviews confirmed the discharge process was not properly followed, and required documentation and communication were lacking.
A resident with complex medical needs was discharged without complete documentation of their discharge plan, disposition, and ADLs. Key sections of the Discharge Summary were left blank, including areas related to skin evaluation, treatments, cognitive/psychosocial status, and medication reconciliation. There was no evidence that the Discharge Summary was provided to or signed by the resident or staff, and CNA documentation of ADLs was incomplete across multiple shifts. The DON acknowledged these documentation gaps, which did not meet federal requirements for medical record maintenance.
A resident with severe cognitive impairment and a history of falls was not provided with adequate supervision or effective fall prevention measures, resulting in a fall that caused a facial laceration and nasal fracture. Despite being identified as a high fall risk, the facility did not increase supervision or implement specific interventions, and staff were not directed to check on the resident within specific timeframes. The facility's Falling Leaf Program was not effectively communicated or implemented, contributing to the resident's injury.
A resident with severe cognitive impairment and multiple medical conditions experienced several falls, including a significant fall resulting in a head injury, at an LTC facility. Despite being identified as a high fall risk, the resident's care plan lacked adequate interventions, and the facility failed to report the incidents to the proper authorities. Staff interviews revealed that the care plan did not include necessary fall prevention measures, and the facility did not consider the incident reportable.
A resident with severe cognitive impairment and a history of impulsivity fell from her wheelchair outside the facility, sustaining a facial laceration and head injury. Despite being a known fall risk, she was left unsupervised, leading to the incident. Staff interviews revealed inconsistencies in the facility's investigation, and the facility's documentation did not align with staff statements. Additionally, the facility failed to identify a nasal fracture noted in the hospital records.
A resident returned to the facility after a hospital visit with a discharge packet that included important medical information, such as a possible nasal fracture. However, the facility failed to scan these records into the EHR, resulting in incomplete documentation. Staff interviews revealed that the records were misplaced, and the attending physician was not informed of the fracture, indicating a breakdown in communication and record-keeping processes.
A resident with liver cirrhosis and metabolic encephalopathy suffered harm due to the facility's failure to administer prescribed medications and monitor her condition. Despite physician orders for Lactulose and Rifaximin, the facility did not provide these medications as required, leading to elevated ammonia levels and a decline in the resident's health. Family concerns and requests for hospital transfer were not promptly addressed, resulting in the resident's hospitalization.
A resident with liver cirrhosis did not receive prescribed Rifaximin due to the facility's failure to complete authorization for this high-cost medication. LPNs documented administering the drug despite its unavailability, with some borrowing from another resident's discontinued supply, violating facility policy. The management was unaware of these issues until identified by surveyors.
The facility failed to serve palatable food at the appropriate temperature to residents in two halls. Several residents complained about cold food, and observations showed that lunch trays were covered with clear plastic covers instead of insulated lids and delivered via a non-insulated cart. The Chef and CDM confirmed that food temperatures were taken 30 minutes before plating, and the facility lacked insulated plate lids and a thermal transport system, leading to the deficiency.
A resident with spinal stenosis, muscle weakness, and rheumatoid arthritis did not receive the prescribed restorative care for range of motion, including splint application, as ordered. Despite the resident's compliance and desire for the splint, it was not applied on several occasions. The Director of Rehabilitation and the Restorative Nurse confirmed the oversight, and the DON acknowledged the resident's cognitive status, confirming the splint should have been applied as ordered.
A resident with COPD was found to have their oxygen concentrator set at 4 liters per minute instead of the prescribed 2 liters. Neither the resident nor their family adjusted the flow rate, indicating a lapse in staff responsibility. Both an LPN and the DON confirmed the discrepancy and acknowledged the importance of adhering to physician orders for oxygen therapy.
Failure to Honor DNR Status and Code Order Changed Without Consent
Penalty
Summary
The facility failed to honor a resident’s expressed DNR wishes by not verifying that her advance directive information was accurately documented before changing her code status to full code. Resident #111 was admitted with a physician order for DNR on the hospital transfer form, and the admitting nurse documented that the DNR wishes were verified with the resident and family on admission. The resident had severe cognitive impairment, multiple serious diagnoses including COPD, acute MI, Alzheimer’s disease, atrial fibrillation, CAD, cancer, and adult failure to thrive, and she was described as frail and medically complex. The next day, a physician order for full code was entered into the EMR without family or resident consent. Facility staff later explained that because a goldenrod DNRO form was not included in the admission packet, they considered the resident to be full code. The 200/400 LPN Unit Manager stated she verified that the admission evaluation form was completed but did not verify that the information was accurate. The Social Services Director stated the team reviewed the hospital records and transfer form, but could not locate an Advance Directive Discussion form or any documentation showing a discussion with the resident or her son about code status. When the resident was found unresponsive, staff initiated CPR and EMS was called. The facility’s code blue worksheet showed staff performed 3 rounds of CPR before EMS arrived and continued resuscitation. EMS continued CPR during transport, intubated the resident, and placed an intraosseous access in her right lower extremity. The resident’s son stated he never gave permission to change his mother’s DNR status and said his mother had expressed that she wanted to be DNR. The attending physician acknowledged he knew the resident and son wanted DNR status and had signed the transfer form indicating DNR, but he still gave a full code order because the goldenrod DNRO form was not included in the admission packet.
Laundry Room Clean and Soiled Linen Not Separated
Penalty
Summary
The facility failed to maintain separation between contaminated and clean laundry processes during a tour of the laundry room with the Housekeeping Manager, Infection Preventionist, and Regional Housekeeping Director. In the dirty area where linen were sorted, three washing machines were observed, and the bins containing soiled linen were very close to the washers with no defined separation of the area. The Housekeeping Manager and Regional Director of Housekeeping stated they were not aware that clean and soiled linen needed to be separated, and they acknowledged that after the wash cycle the linen were clean, so having the bins with dirty linen so close to the washers when emptied could cause possible cross contamination of linen. The facility's Infection Prevention and Control Plan 2026 stated the program is designed to prevent, identify, report, investigate and control the spread of infections and communicable disease in the facility.
Delayed Pain Medication Administration
Penalty
Summary
The facility failed to provide safe, appropriate pain management for two residents who had physician-ordered opioid analgesics for non-acute pain. One resident had diagnoses including a right patella fracture, nasal bone fractures, rheumatoid arthritis, head injury, and muscle weakness, and her MDS showed moderate cognitive impairment with occasional pain. Her care plan directed staff to administer analgesia per orders because of pain risk related to arthritis, fracture, impaired mobility, multiple co-morbidities, and postoperative discomfort. She told staff she had been waiting for pain medication since early morning and could not attend therapy because of pain, yet the medication was not administered until later that morning. The MAR also showed multiple prior doses of the scheduled hydrocodone-acetaminophen were given about two and a half hours late, and there were no progress notes explaining the delays. A second resident had diagnoses including aftercare following joint replacement surgery, unilateral primary osteoarthritis of the right knee, and pain in an unspecified joint. Her MDS showed she was cognitively intact and had frequent pain. Her care plan also directed staff to administer analgesia per physician orders. She reported that pain medication was not being given on time and stated she wanted to leave the facility because of the delays. On one documented day, the scheduled oxycodone-acetaminophen doses were not administered as ordered: one dose was marked as medication on order from pharmacy, another dose was documented with a code indicating the medication was not given as scheduled, and the 12 PM dose was given later than scheduled. The resident later received an emergency order dose at night. The facility’s medication administration standards stated medications are to be administered within one hour before or after the prescribed time unless otherwise specified, and if a drug is withheld, refused, or given at a different time, the reason must be documented in the resident’s medical record and the physician and responsible party notified if indicated. Staff interviewed stated that late medication administration should be documented and reported, but the record for the delayed doses did not contain corresponding progress notes explaining why the medications were given late or not given as scheduled.
Medication Administration Error Rate Exceeded Threshold
Penalty
Summary
Medication administration errors exceeded the 5 percent threshold for resident #101, with 2 errors in 32 opportunities for a 6.25% error rate. During an observation on 04/27/2026 at 9:00 AM, LPN B removed Folic Acid 1 mg, Apixaban 5 mg, Midodrine 5 mg, Midodrine 10 mg, Sodium Chloride 1 mg, Miralax 1 capful, and an Advair inhaler for resident #101. During reconciliation of the MAR, Potassium Chloride 20 meq and Sertraline 50 mg were marked as given even though they were not administered during the observation. On 4/28/26 at 11:48 AM, the Unit Manager for the 200 and 400 Halls was informed of the medication error and stated that medications are expected to be administered according to physician orders, including the ordered frequency and time.
Failure to Provide and Document Ordered Wound and Dermatologic Treatments
Penalty
Summary
The deficiency involves the facility’s failure to provide timely, consistent, and properly documented dermatologic and wound treatments as ordered and care planned for two residents. For one resident admitted for nerve pain, the care plan identified a pressure ulcer on the buttocks and risk for skin impairment, with interventions including weekly skin checks, measurements of the wound, nutritional support, preventive skin treatments, and prompt incontinence care. Physician orders directed cleansing of bilateral lower legs with normal saline, patting dry, and wrapping with a dry dressing every evening shift, as well as cleansing an area between the buttocks with 1/4 Dakins and applying zinc oxide every shift. Review of the Treatment Administration Record (TAR) showed missing treatments for the lower leg wound care order on multiple dates and missing treatments for the buttocks wound care order on several shifts. Further review showed an additional physician order for wound care to bilateral lower legs every dayshift, also with missed treatments documented on the TAR. The wound care nurse stated her responsibilities were limited to residents with stage three or greater pressure wounds, while "cart nurses" were responsible for less severe wounds and weekly wound assessments. An LPN identified as a cart nurse reported that she completed wound assessments weekly and provided wound treatments when ordered, and that she always completed treatments by the end of her shift or notified the next shift or manager if unable to do so. Despite these statements, the TAR documentation reflected that ordered treatments for this resident’s wounds were not consistently completed as prescribed. For another resident admitted with a several-week history of a rash on both feet, a dermatology consultation diagnosed tinea pedis and prescribed 2% Ketoconazole cream to be applied daily to both feet until resolved. On interview, the dermatologist confirmed the daily application order and stated that failure to apply the cream as ordered could result in worsening fungal infection and secondary complications. Multiple LPNs gave conflicting information regarding the use and availability of the Ketoconazole cream: one LPN initially stated she applied the cream to the resident’s belly button, then corrected herself to say it was for the feet, and presented an unopened tube dated with the resident’s name, explaining that a previous tube had been thrown away that morning. Other LPNs stated that only one tube had been obtained from the pharmacy, that it had not been refilled, and that the tube should last approximately two and a half to three weeks if used as ordered. Family members reported the resident had not received the prescribed cream for several days after admission and expressed concern that the ordered daily treatment had been missed.
Failure to Provide Sufficient Nursing Staff and Timely Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs and preferences of residents, as evidenced by prolonged call light response times and unmet care needs for multiple residents. Observations revealed that call lights remained unanswered for extended periods, with one resident waiting 25 minutes and another 20 minutes. Residents were observed calling out for assistance, and staff were not present in the hallways during these times. One resident, who had recently returned from the hospital after an amputation, was left waiting for pain medication, reporting severe pain and a significant delay since his last dose. His care plan required timely pain management, but the delay in response resulted in unmanaged pain. Another resident, dependent on staff for transfers, reported waiting approximately 30 minutes for assistance to return to bed and described routine delays due to staffing shortages. She expressed frustration with the long wait times and noted that CNAs were overworked, handling multiple responsibilities simultaneously. A third resident, with a history of respiratory issues and anxiety, also experienced delays in receiving her inhaler before scheduled therapy, leading to increased anxiety and physical symptoms. She noted that long wait times for call light responses were consistent regardless of shift or day. Staff interviews confirmed that call lights were often left unanswered due to heavy workloads and insufficient staffing, particularly during night shifts and meal service times. CNAs reported being assigned to multiple residents with high care needs, making it difficult to respond promptly to all requests. Resident Council meeting minutes and interviews with the Resident Council President highlighted ongoing concerns about staffing shortages, which had been repeatedly discussed without resolution. Facility policies required prompt call light response, and the facility assessment acknowledged the need for staffing adjustments based on resident acuity and care needs, but these standards were not met in practice.
Inaccurate MDS Medication Documentation
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the prescribed medications for a resident with multiple complex diagnoses, including multiple sclerosis, major depressive disorder, anxiety, seizures, bipolar disorder, brief psychotic disorder, and psychosis. After being readmitted from an acute care hospital, the resident was prescribed several medications, including antidepressants, anticonvulsants, antipsychotics, antibiotics, and opioids. Review of the Medication Administration Report (MAR) confirmed that these medications were administered during the seven-day lookback period relevant to the MDS assessment. However, the MDS assessment completed for the resident did not accurately document all the medication classes received, specifically omitting antipsychotic, antidepressant, and opioid medications in Section N. The MDS Lead confirmed that the assessment should have included these drug classes and explained that the assessment was completed by a new MDS Coordinator. Corporate audits of MDS assessments were performed only on a random basis, and the facility's policy required comprehensive and accurate assessments using the Resident Assessment Instrument (RAI).
Failure to Complete PASARR After Significant Change in Mental Condition
Penalty
Summary
The facility failed to ensure the completion and accuracy of a Level I Preadmission Screening and Resident Review (PASARR) following the readmission of a resident with a diagnosis of Serious Mental Illness (SMI) after a significant change in her mental condition. The resident, who had a history of multiple sclerosis, major depressive disorder, anxiety, and seizures, was readmitted from an acute care hospital and subsequently developed additional psychiatric diagnoses, including bipolar disorder, brief psychotic disorder, and psychosis. Despite these new diagnoses and significant behavioral changes, there was no evidence that a new Level I PASARR was completed after her readmission or following the onset of new psychiatric symptoms. The resident exhibited a range of severe behavioral symptoms, including hallucinations, delusions, impulsivity, aggression, resisting care, and socially inappropriate behaviors. Progress notes documented multiple incidents where the resident called 911, refused medications, food, and drink, and required emergency interventions such as the administration of psychotropic medications and involuntary psychiatric holds under state law. The medical record also showed ongoing psychiatric evaluations and medication adjustments due to persistent psychosis, agitation, and mood instability. Despite these significant changes, the PASARR documentation in the record was incomplete, with key sections left blank and no indication that a Level II evaluation was considered or initiated. Interviews with facility staff, including the LPN, Social Services Assistant, DON, and Administrator, confirmed that the PASARR was not reviewed or resubmitted after the resident's significant behavioral changes and new psychiatric diagnoses. The DON acknowledged that a new PASARR should have been completed in such circumstances, and the Administrator admitted the omission was an oversight. Additionally, the facility lacked a policy defining which staff member was responsible for updating PASARRs, and no behavioral health or behavior management policy was provided upon request.
Failure to Follow Hand Hygiene and PPE Protocol During IV Infusion
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper hand hygiene and personal protective equipment (PPE) protocols while assisting a resident with an intravenous (IV) infusion. The resident, who had a midline catheter for anemia treatment and multiple diagnoses including metabolic encephalopathy, type 2 diabetes, stroke, and weakness, was observed during the setup of an iron infusion. The LPN exited the resident's room wearing gloves, used scissors from the medication cart to open an IV-line package outside the room, and then reentered the room still wearing the same gloves. Inside, the LPN continued to handle the IV line and moved a trash can without changing gloves or performing hand hygiene. The LPN later confirmed that she did not remove her gloves or perform hand hygiene when leaving and reentering the resident's room, acknowledging that this was a violation of infection control protocol. The Director of Nursing (DON) stated that staff are expected to remove gloves and perform hand hygiene before exiting a resident's room. Facility records indicated that all staff receive infection control and hand hygiene education upon hire and annually.
Repeated Deficiency in Medical Record Documentation Due to Inadequate QAPI Oversight
Penalty
Summary
The facility failed to implement its Quality Assurance and Performance Improvement (QAPI) policies to ensure thorough monitoring and tracking of previously identified areas of concern, specifically regarding the accuracy of medical record documentation. Despite having a QAPI program with objectives to monitor and evaluate corrective actions, the facility had repeated deficiencies at F842, related to medical record accuracy, identified during complaint surveys. The review of documentation showed that education was provided to nursing staff and audits were planned, but the same deficiency was cited again in subsequent surveys, indicating that the measures taken were not effectively monitored or sustained. During interviews, the Administrator reported limited participation in QAPI meetings since starting at the facility and was unaware of the previous deficiencies related to medical records documentation. The repeated citation of F842 demonstrated insufficient auditing and oversight by the QAPI team, as the facility did not ensure that prior improvement measures were realized and maintained, leading to ongoing non-compliance with documentation standards.
Incomplete Discharge Documentation and Notification
Penalty
Summary
A deficiency occurred when the facility failed to provide a complete written discharge summary and a list of medications to a resident upon discharge. The resident, who had diagnoses including nontraumatic subacute subdural hemorrhage, COPD, type 2 diabetes, repeated falls, and mobility issues, was readmitted to the facility and later discharged home. The discharge summary form in the medical record was incomplete, with several sections left blank, including skin evaluation, treatments, cognitive/psychosocial status, ADLs, sensory, dietary, rehabilitation services, and education/acknowledgement. The section for instructions after discharge was only partially completed, and the medication list, pharmacy details, and documentation of scripts provided were not addressed. There was no evidence that the discharge summary was given to the resident or signed by either the resident or staff, nor was there documentation of medication reconciliation or confirmation that medications were provided upon discharge. Interviews with facility staff revealed a lack of documentation and communication regarding the discharge process. The resident's sister, who was listed as the health care surrogate and POA, reported she was not notified in advance of the discharge and only received a call after the resident had left. Staff interviews indicated that the discharge was not planned according to standard procedures, and there were no progress notes or documentation of discharge planning or education provided to the resident. The Social Services Assistant and DON confirmed that the discharge summary was incomplete and not signed, and that the physician order for discharge and referral to home health were not completed until the day after the resident left. Attempts to contact the nurses and CNAs who worked during the discharge period were unsuccessful, and there was no documentation in the progress notes regarding the discharge. The facility's policy required an effective discharge process, including preparation of residents for transition and provision of necessary documentation. However, the process was not followed in this case, as evidenced by the incomplete discharge summary, lack of medication documentation, and absence of communication with the resident's designated representative. The discharge occurred without proper planning, documentation, or notification, resulting in a failure to meet regulatory requirements for resident discharge.
Incomplete Discharge Documentation and ADL Records
Penalty
Summary
The facility failed to accurately document the discharge plan, disposition, and Activities of Daily Living (ADLs) for a resident who was readmitted with multiple diagnoses, including a subacute subdural hemorrhage, COPD, diabetes, repeated falls, and mobility issues. The resident's quarterly MDS assessment indicated an active discharge plan for return to the community, but the Discharge MDS later documented a planned discharge home with return not anticipated. The Discharge Summary form was incomplete, with several sections left blank, such as Skin Evaluation, Treatments, Cognitive/Psychosocial, ADLs/Functional Status, Sensory, Dietary, Rehabilitation Services, and Education/Acknowledgement. The Instructions After Discharge section was only partially completed, and there was no documentation of medication reconciliation, pharmacy details, or confirmation that medications or scripts were provided upon discharge. Additionally, there was no evidence that the Discharge Summary was given to or signed by the resident or staff. Review of the resident's physician orders and progress notes did not reveal any entries regarding discharge planning, education provided, or disposition of medications. Documentation of ADL tasks by CNAs was found to be incomplete, with multiple shifts showing blank entries for care provided. The DON confirmed that staff were expected to document care as close as possible to the time it was performed and acknowledged the incomplete and unsigned Discharge Summary. The facility's Medical Records policy required maintenance of records per federal requirements, which was not met in this instance.
Inadequate Supervision Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate interventions to prevent falls for a resident with a history of repeated falls, resulting in actual harm. The resident, an elderly female with severe cognitive impairment and multiple medical conditions, was admitted to the facility with a history of impulsivity and a need for substantial assistance with mobility. Despite being identified as a high fall risk, the facility did not increase supervision or implement effective fall prevention measures after the resident experienced multiple falls. The resident had a history of falls, including four incidents in September, none of which were witnessed by staff. On one occasion, the resident was found on the floor with a head laceration after attempting to transfer herself. Despite these incidents, the facility did not implement increased supervision or specific interventions to address the resident's fall risk. The resident's care plan lacked detailed instructions for supervision, and staff were not directed to check on her within specific timeframes. The facility's failure to provide one-on-one supervision or frequent checks contributed to the resident's fall on October 5th, resulting in a facial laceration and a nasal fracture. Interviews with staff revealed that the resident was known to be impulsive and frequently attempted to move around unsupervised. Staff expressed concerns about the resident's safety and the difficulty of monitoring her while attending to other residents. Despite these concerns, the facility did not provide additional supervision or implement effective fall prevention strategies. The facility's Falling Leaf Program, intended to alert staff to high fall risk residents, was not effectively communicated or implemented, and the resident's care plan did not reflect the necessary interventions to prevent falls.
Failure to Report Possible Neglect After Resident's Falls
Penalty
Summary
The facility failed to report possible neglect for a resident who experienced multiple falls, including a significant fall that resulted in a head injury and a possible nondisplaced nasal bone fracture. The resident, an elderly female with severe cognitive impairment and multiple medical conditions, was admitted to the facility with a history of acute respiratory failure, sepsis, and dementia, among other diagnoses. Despite being identified as a high fall risk, the resident's care plan lacked adequate interventions to prevent falls, such as frequent checks or a fall program. The resident experienced several falls in September, none of which were witnessed by staff, and the facility did not report these incidents to the proper authorities. On one occasion, the resident was found alone on the patio, having fallen from her wheelchair, resulting in facial lacerations and altered consciousness. The facility's investigation concluded that the resident was independent with wheelchair propulsion and did not consider the incident reportable, as they believed the resident was supervised in an enclosed area. Interviews with facility staff revealed that the resident's care plan did not include the Falling Leaf Program or frequent checks, despite being a high fall risk. The facility's Director of Nursing and Nursing Home Administrator did not report the incident to the state agency, as they believed the care plan was followed and were unaware of the possible fracture. The facility's standards and guidelines define neglect as the failure to provide necessary goods and services to avoid harm, yet the facility did not report the incident as neglect.
Failure to Investigate and Supervise Leads to Resident Fall
Penalty
Summary
The facility failed to thoroughly investigate and identify possible neglect for a resident who was severely cognitively impaired and had a history of impulsivity. The resident, who required substantial assistance for mobility and activities of daily living, was found outside alone and had fallen from her wheelchair, sustaining a facial laceration and a head injury. Despite being a known fall risk, the resident was left unsupervised, leading to the incident. Staff interviews revealed inconsistencies in the facility's investigation. Certified Nursing Assistants (CNAs) and a Licensed Practical Nurse (LPN) provided conflicting accounts of the supervision and checks conducted on the resident. The CNAs were expected to conduct 15-minute checks due to the resident's severe dementia and fall risk, but the resident was left alone outside, resulting in the fall. The facility's documentation and investigation did not align with the staff's statements, indicating a lack of thorough investigation and communication. The facility's investigation documents were incomplete, missing statements from key staff members involved in the incident. Additionally, the facility's review of the resident's emergency room visit failed to identify a nasal fracture, which was noted in the hospital records. The Director of Nursing (DON) and the Nursing Home Administrator acknowledged the discrepancies in the investigation and the lack of awareness of the resident's full medical condition post-fall.
Incomplete Medical Records for Resident Post-Hospital Discharge
Penalty
Summary
The facility failed to maintain a complete and readily accessible medical record for a resident who was reviewed for administration. The resident, an elderly female, was admitted to the facility with multiple diagnoses including acute respiratory failure, sepsis, and dementia. After a fall resulting in a head injury, she was transported to the hospital and returned with a discharge packet that included prescriptions and test results. However, the facility was unable to locate these records, which included a CT scan indicating a possible nasal fracture. Interviews with staff revealed that the hospital discharge packet was placed in a drawer at the nurse's station but was not scanned into the electronic health record (EHR) as required. The Medical Records Clerk confirmed that the records were not scanned and were missing. The Director of Nursing and other staff members acknowledged the importance of having complete records for clinical review but were unable to explain the absence of the records. The attending physician and Medical Director were not informed of the nasal fracture, highlighting a communication breakdown in the facility's process for handling hospital discharge information. The deficiency was further compounded by the lack of follow-up actions to retrieve the missing records. Despite the facility's protocol for reviewing hospital discharge records in morning meetings, the records were not available for review, and no one had requested them from the hospital. This oversight resulted in incomplete documentation and a lack of awareness among the clinical team regarding the resident's nasal fracture, which was crucial for her ongoing care and monitoring.
Failure to Administer Medications and Monitor Condition Leads to Resident Harm
Penalty
Summary
The facility failed to provide care and services according to professional standards of practice, resulting in actual harm to a resident with liver cirrhosis and metabolic encephalopathy. The resident was admitted with physician orders for Lactulose and Rifaximin to manage hyperammonia, but the facility did not administer these medications as prescribed. The resident's ammonia levels were not adequately monitored, and there was a delay in responding to elevated ammonia levels, leading to a deterioration in the resident's condition. The resident exhibited symptoms of high ammonia levels, such as nausea, confusion, and lethargy, which were not promptly addressed by the facility staff. Despite family members expressing concerns and requesting hospital transfer, the facility delayed action, resulting in the resident's condition worsening to the point of requiring hospitalization. The facility's documentation did not accurately reflect the resident's declining condition, and there were discrepancies in medication administration records. Interviews with facility staff revealed communication breakdowns and a lack of timely response to the resident's changing condition. The facility's pharmacy records indicated that only a limited supply of Rifaximin was dispensed, and there was no follow-up to ensure the resident received the necessary medication. The facility's failure to adhere to medication orders and promptly address the resident's symptoms contributed to the resident's hospitalization and harm.
Deficiency in Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident with liver cirrhosis and metabolic encephalopathy, leading to a deficiency in medication administration. The resident was prescribed Lactulose and Rifaximin to manage hyperammonia, a condition associated with hepatic encephalopathy. However, the facility did not ensure the availability of Rifaximin, resulting in missed doses over several days. The medication was categorized as high-cost, requiring special authorization, which was not completed by the facility, leading to a lack of supply. Multiple Licensed Practical Nurses (LPNs) documented administering Rifaximin despite its unavailability, with some admitting to borrowing the medication from another resident's discontinued supply. This practice was against the facility's policy, which prohibits administering medications prescribed for one resident to another. The facility's management was unaware of the medication shortage and the inappropriate borrowing practice until it was identified by the State Survey Agency staff. The facility's investigation revealed that the pharmacy had sent multiple requests for authorization to dispense additional Rifaximin, but these were not returned by the facility. The Assistant Director of Nursing confirmed that a card of Rifaximin with 17 pills was found during an audit, which should have been returned to the pharmacy. The facility's failure to manage medication orders and returns properly, along with the inappropriate actions of the nursing staff, contributed to the deficiency in pharmaceutical services.
Deficiency in Serving Palatable Food at Appropriate Temperature
Penalty
Summary
The facility failed to serve palatable food at the appropriate temperature to residents in two of its halls, specifically the 300 and 600 halls. During the recertification survey, several residents complained about receiving cold food. Observations revealed that the lunch trays for the 600 hall were covered with clear plastic covers instead of insulated dome lids, which were used for other trays. The lunch trays were delivered via a non-insulated, non-heated metal cart, and the food was found to be lukewarm and not palatable by the surveyors. The Chef and Certified Dietary Manager confirmed that the steam table temperatures were taken 30 minutes before the first meal was plated, and the food met temperature standards at that time. However, the facility was missing 25-30 insulated plate lids, and it did not use a thermal food transport system to maintain hot food temperatures during meal service. This contributed to the deficiency of serving cold food to residents, as evidenced by the complaints and observations made during the survey.
Failure to Implement Restorative Care for Resident's Range of Motion
Penalty
Summary
The facility failed to implement the recommended restorative care for a resident, leading to a deficiency in maintaining and improving the resident's range of motion. The resident, who was admitted with spinal stenosis, muscle weakness, and rheumatoid arthritis, had an active physician's order for a restorative nursing program that included passive range of motion and splint application for his left hand. Despite the resident's compliance and desire to have the splint applied, observations and interviews revealed that the splint was not applied on several occasions, including specific dates in July. The resident reported that the splint was supposed to be applied daily but had not been applied several times over the past week and on specific days. The Director of Rehabilitation and the Restorative Nurse confirmed that the resident was to have the splint applied 4-5 days a week for 4-6 hours each time, as prescribed. However, the task report showed that the splint was not applied on multiple days, and the resident had not refused the application. The Director of Nursing acknowledged the resident's cognitive status and confirmed that the splint should have been applied as ordered. The facility's Restorative Nursing Services Standards and Guidelines emphasize promoting the resident's optimum function through a restorative nursing program, which was not adhered to in this case.
Failure to Maintain Prescribed Oxygen Flow Rate
Penalty
Summary
The facility failed to maintain the prescribed oxygen flow rate for a resident with chronic respiratory conditions, including COPD. The resident was admitted with a physician's order for continuous oxygen at 2 liters per minute via nasal cannula. However, during an observation, the oxygen concentrator was found to be set at 4 liters per minute. The resident and a family member confirmed that neither had adjusted the flow rate, indicating a lapse in staff responsibility. Licensed Practical Nurse (LPN) A and the Director of Nursing both acknowledged the discrepancy between the physician's order and the actual oxygen flow rate. They confirmed that it was the nurse's responsibility to ensure the oxygen settings matched the physician's order and to monitor these settings regularly. The facility's guidelines also emphasized the importance of adhering to physician orders for oxygen therapy. This oversight could potentially lead to respiratory distress or oxygen toxicity, particularly in a resident with COPD.
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What surveyors actually found near you
We read the 44 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Viera
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Viera Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 7 | 0 |
| Nursing & Rehabilitation Center Of Melbourne | 7.2 mi | ★★★★★ | 13 | 0 |
| Sunrise Point Health And Rehabilitation Center | 7.5 mi | ★★★★★ | 2 | 2 |
| The Terrace At Courtenay Springs | 7.8 mi | ★★★★★ | 5 | 0 |
| Rockledge Healthcare & Rehabilitation Center | 7.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.