Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to give written notice, including the reason for the move, before changing room assignments for three residents. One cognitively intact resident with chronic pain and anxiety had two room changes with no documentation of consultation or consent; another cognitively intact resident with COPD, CHF, and pericardial effusion was moved without written notice to him or his POA; and a third resident with DVT, weakness, and MDD was told of the move only after her belongings had already been moved. Staff and leadership stated room changes were handled verbally and there was no formal written notification process, despite the facility policy requiring written notice before a room or roommate change.
Unsafe food storage and unsanitary kitchen conditions were identified in the kitchen and a nourishment room. Surveyors observed soiled storage racks, stained ceiling tiles above the dishwashing area, and baking pans with dried food residue. In the nourishment room refrigerator, unlabeled resident food items and an unlabeled cup of ice were stored with a staff member’s beverage, despite staff stating the refrigerator was for resident items only and that resident food had to be labeled with a name or room number and date.
Refuse storage was not maintained in a sanitary condition in the kitchen exterior dumpster area. Surveyors observed 2 dumpsters with lids not tightly closed because trash was protruding from the top, and debris, including plastic gloves, was scattered on the ground. The CDM and Maintenance Director acknowledged the findings, and the Maintenance Director stated staff were responsible for keeping garbage contained and lids closed to prevent vermin.
A cognitively intact resident with hemiplegia, difficulty walking, and a short-stay rehab plan was not allowed to use her own motorized wheelchair and was required to use a facility wheelchair instead. She stated staff did not assess her ability to safely operate the chair, and interviews with OTA, PTA, the DOR, and the Administrator confirmed the facility generally did not allow electric wheelchairs due to safety concerns. The record contained no documentation that nursing or therapy assessed her for safe use of the power chair, despite facility policy stating residents who can safely and competently use motorized wheelchairs should be allowed to do so.
Failure to Promptly Resolve a Resident Grievance: A cognitively intact resident with CAD, COPD, dementia, and MDD and his wife reported multiple unresolved concerns, including wanting him out of bed more often. Staff gave conflicting accounts about a grievance filed on the resident’s behalf, and the grievance record lacked documentation showing it was resolved or that a written decision was provided, despite the facility policy requiring prompt grievance resolution.
Failure to assist a resident with hearing aid use. A resident with dementia, weakness, and hearing loss had care plan interventions for staff to help place and remove bilateral hearing aids, but she was repeatedly observed without them while in common areas and dining. Her daughter reported staff were not helping, the grievance log documented the complaint, the audiologist reminded nursing staff to assist with placement, and CNA task records showed many missed entries for hearing aid assistance.
Inaccurate documentation of topical medication administration was found for a resident with cellulitis, PVD, respiratory failure, and multiple skin conditions including stasis dermatitis and seborrheic dermatitis. An LPN observed giving oral meds documented Hibiclens, ketoconazole shampoo, and urea cream before they were actually administered, and the resident stated the creams and shampoo had not been applied that day. The DON acknowledged the MAR was inaccurate because it showed treatments as completed when they were not.
A resident with a stage 3 pressure ulcer did not receive adequate care as ordered by the physician, with wound care not performed on two days and recommended supplements omitted from the treatment plan. The LPN responsible for wound care failed to check the physician's notes for new orders, and the DON confirmed the lack of documentation and follow-through on the physician's recommendations.
The facility failed to ensure effective communication and collaboration with a dialysis center, leading to inadequate treatment for two residents. One resident did not receive prescribed medication due to availability issues, while another experienced incomplete documentation and missed meals before dialysis. The facility's communication lapses and documentation failures contributed to these deficiencies.
A resident with ESRD and nephritic syndrome did not receive prescribed Sevelamer Carbonate due to pharmacy delays, yet the MAR inaccurately recorded its administration. The facility's documentation and communication with the pharmacy and dialysis center were insufficient, as acknowledged by the Transitional Care Unit Manager and DON.
A CNA failed to follow proper infection control practices by handling soiled linens and hospital gowns without changing gloves or performing hand hygiene, as confirmed by the DON. The CNA admitted to not adhering to protocols due to workload pressures, despite having completed infection control training.
A resident with a feeding tube and moderate depression was not included in care plan meetings after being readmitted to the facility. Despite expressing a desire to have her feeding tube removed and to be discharged, the facility failed to reschedule a care plan meeting that was missed due to her hospital discharge. The MDS Coordinator admitted the oversight, and the DON highlighted the importance of these meetings for understanding care and discharge plans.
A resident with severe cognitive impairment eloped from a facility due to inadequate supervision and failure to update the care plan with effective interventions. The resident, who had a history of dementia and was supposed to be wearing an electronic wander monitoring bracelet, exited the facility unnoticed and unsupervised. The facility's Weekend Supervisor failed to notice the resident following a visitor out the door, leading to the resident being unsupervised for approximately 30 minutes.
A resident with severe cognitive impairment exited a facility unsupervised due to inadequate supervision and security measures. The resident, known for wandering and exit-seeking behaviors, left unnoticed when a supervisor unlocked the door for a visitor. The facility failed to update the care plan with necessary interventions despite escalating behaviors, leading to the resident being outside for 45 minutes before being found by an off-duty staff member.
A resident with severe cognitive impairment eloped from the facility after following a visitor out the door. Despite exhibiting increased anxiety and wandering behavior, the resident was not placed under one-to-one supervision. The facility's investigation was incomplete, with inconsistent staff statements and insufficient follow-up, failing to adhere to their policy on abuse, neglect, and investigation.
Failure to Provide Written Notice Before Room Changes
Penalty
Summary
The facility failed to provide written notice, including the reason for the change, before changing the room assignment for 3 of 5 residents reviewed for choices. The deficiency involved residents #2, #6, and #79, all of whom had room changes documented in the record, but the records did not show that they or their representatives were given written notification before the moves occurred. Resident #2 was a cognitively intact female with diagnoses including chronic pain syndrome, muscle spasm, low back pain with sciatica, and generalized anxiety disorder. Her record showed room changes on 11/01/25 and 1/03/26, but there was no documentation that she or her representative was informed in writing or consulted about either change. During interview, she stated she did not like being in the room with her current roommate and described the situation as terrible. The Social Services Director reviewed the record and could not find documentation of consultation or consent for the room changes. Resident #79 was cognitively intact with diagnoses including pericardial effusion, COPD, and CHF, and his MDS indicated it was very important to him to have family or a close friend involved in care discussions. His record did not contain documentation that written notice, including the reason for the change, was provided before a room change. He stated he was told he was being moved but was not told why, and his POA said she learned of the move only when he called her while she was on the way to the facility. Resident #6 had diagnoses including acute embolism and thrombosis of the left calf muscular vein, difficulty walking, muscle weakness, and major depressive disorder. Her record also lacked documentation of written notice before the room change, and she stated she was informed while outside in the courtyard and returned to find her belongings already moved; she was told the room was needed for two male admissions. Facility staff and leadership stated room changes were typically handled verbally and that there was no formal written notification process, despite the facility policy requiring written notice with the reason for the change before a resident's room or roommate is changed.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Food was not stored, prepared, and maintained in a safe and sanitary manner in the main kitchen and in 1 of 2 nourishment rooms. During the initial kitchen tour, multiple lids were stored on a rolling rack with visible food debris and residue on the shelving surfaces and rack bars, and the rack itself was soiled with dried food particles on the horizontal supports. The kitchen ceiling above the dishwashing area had multiple ceiling tiles with visible dark spots, stains, and discoloration. Multiple baking pans also contained dried food residue. The Certified Dietary Manager validated these findings and did not provide an explanation for the condition of the items. In the Residential Care Unit nourishment room, a sandwich wrapped in aluminum foil and a bag of lemon sugar cookies were found in the refrigerator door without a resident name, room number, or date. A Styrofoam cup containing ice was also in the refrigerator door without identification, and a Styrofoam cup containing liquid labeled with a staff member's name and CNA designation was stored inside the top rack of the refrigerator. CNA I stated staff were instructed to store food and beverages in the staff break room refrigerator, not in the nourishment room refrigerator, and discarded the staff cup and the unlabeled cup of ice. The Unit Manager confirmed the refrigerator was for resident food items only and that resident items required a name or room number and date, with items discarded after 72 hours. The Administrator stated staff beverages should not be stored in the nourishment room refrigerator and resident food items must be labeled with a name or room number and date. The facility policy stated nursing staff were to label containers with the food item name and date received.
Refuse Area Not Kept Sanitary
Penalty
Summary
The facility failed to maintain the refuse storage area in a sanitary condition to prevent odors and the attraction of pests for 2 of 2 dumpsters observed in the exterior kitchen refuse area. During the initial tour of the kitchen, surveyors observed two large waste dumpsters with lids that were not tightly closed, with plastic trash protruding from the top and preventing full lid closure. The surrounding ground surface also contained scattered refuse debris, including four plastic gloves. The Certified Dietary Manager and the Maintenance Director acknowledged these findings during the tour. Later, the Maintenance Director stated that kitchen, housekeeping, and maintenance staff were responsible for disposing of trash in the dumpsters, ensuring garbage was contained, debris was not left on the ground, and lids were kept closed to prevent vermin; he also stated he did not know where the discarded gloves came from and that garbage was not collected on Sundays.
Resident Choice Not Honored for Motorized Wheelchair Use
Penalty
Summary
The facility failed to promote resident rights related to resident choice when it did not allow a cognitively intact resident to use her own motorized wheelchair. Resident #104 was admitted with diagnoses including orthopedic aftercare, displacement of internal fixation device of vertebrae, hemiplegia and hemiparesis following cerebral infarction affecting her left non-dominant side, and difficulty walking. Her MDS admission assessment showed a BIMS score of 15 out of 15, indicating she was cognitively intact, and it documented that she used a manual wheelchair and could independently propel at least 150 feet. Her care plan noted she was a short-stay resident who clearly expressed a desire to discharge and return home where she lived alone. The record also showed that prior to admission she used a large electric wheelchair primarily for mobility in the home and community and a smaller foldable electric wheelchair for community outings. The resident stated the facility did not allow her to use her own wheelchair and required her to use a facility wheelchair. She reported the facility did not test her ability to use the wheelchair in manual mode or assess her ability to safely operate it. Staff interviews confirmed she wanted to use her electric wheelchair, but OTA, PTA, the DOR, and the Administrator stated electric wheelchairs were not generally used or were not allowed in the facility due to safety concerns. The medical record contained no documentation that therapy or nursing assessed her ability to safely use her motorized wheelchair, despite the facility policy stating residents who can safely and competently use motorized wheelchairs should be allowed to do so and that therapy and/or nursing would determine the need based on assessment.
Failure to Promptly Resolve a Resident Grievance
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for resident #94, who was admitted with diagnoses including atherosclerotic heart disease, chronic obstructive coronary disease, unspecified dementia, and major depressive disorder. A quarterly MDS assessment showed the resident was cognitively intact with a BIMS score of 13 out of 15 and had no behaviors or care refusals. During an interview on 2/11/26, the resident and his wife stated they had voiced multiple concerns to the facility, but the issues did not seem to be addressed. The wife said she had filed a grievance the prior month and had not heard anything back, and she did not recall signing a grievance or being told there was any resolution to her concerns. The resident stated he wanted to be taken out of bed more often and had been asking for a long time, but staff often reported that he refused when his wife asked. Facility staff gave conflicting accounts about the grievance and its resolution. The Social Services Director, who was also the Grievance Officer, said grievances were usually forwarded to the responsible department and typically took about two weeks to resolve, but the grievance filed on behalf of resident #94 on 1/21/26 did not appear to be resolved. The RCU Unit Manager said she did not know anything about the grievance and suggested it may have taken longer because the family could not be contacted, while the ADON stated it had been resolved over the phone with the resident's wife. The grievance form did not indicate that it was resolved and contained no signatures or dates documenting resolution. The facility policy stated it would make prompt efforts to resolve grievances and provide a written decision, but the grievance remained unresolved in the record and the same concerns were still being discussed at the care plan meeting the next day.
Failure to Assist with Hearing Aid Use
Penalty
Summary
The facility failed to ensure hearing aid assistance was provided for a resident with dementia, generalized weakness, retinopathy, and hearing loss-related needs. The resident’s record showed she had bilateral hearing aids and care plan interventions directing staff to assist her with putting them in each morning, removing them each evening, and changing batteries every 10 days. Her MDS assessments indicated she was moderately cognitively impaired and that her hearing aid provided adequate hearing ability if normally used. During observation, the resident was repeatedly found without her hearing aids in place while sitting in common areas and dining with others. On one occasion, her daughter stated staff were not assisting with hearing aid placement despite complaints to management, and that the resident enjoyed socializing and would benefit from wearing them. The care plan review note also reflected that the resident enjoyed interactions with staff and other residents and that hearing services were discussed with the daughter. Record review and staff interviews showed the issue persisted despite the complaint. The grievance log documented the daughter’s complaint about hearing aid placement, and the audiologist noted the resident was not wearing her hearing aids and reminded nursing staff to assist with placement and removal. CNA task records from mid-January through the survey date showed many entries marked “No” for hearing aid assistance, and staff interviews confirmed CNAs were responsible for assisting with the devices. The resident was observed again without her hearing aids at the end of the survey period, and staff stated they were unaware of any issues with the hearing aids.
Inaccurate Documentation of Topical Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurately documented clinical records for medication administration for one resident observed for medication administration. Resident #33 was admitted with diagnoses including cellulitis of the left lower limb, respiratory failure, peripheral vascular disease, and rash, and had intact cognition with a brief interview of mental status score of 15 out of 15. The resident’s care plan included skin impairments such as a rash in the abdominal folds, scalp seborrheic dermatitis, a right dorsal hand wound, and stasis dermatitis on both lower legs, with physician orders for Urea External Cream 40% to the bilateral lower legs, Hibiclens External Solution 4% to the lower legs, and Ketoconazole External Shampoo 2% to the scalp. During observation of medication administration, an LPN administered five oral medications to the resident. A later review of the MAR and medication administration audit report showed the topical medications were documented as given at times when they had not yet been administered. The resident stated that no creams or shampoo had been applied that day, and the LPN acknowledged documenting the medications after providing treatment or giving medication, but in this instance documented them before they were actually administered. The DON acknowledged the MAR was inaccurate because it showed the treatments as completed when they were not, and stated the expectation was to document immediately after medications or treatments were administered, not beforehand.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate care and services to promote the healing of a sacral pressure ulcer for a resident, as ordered by the physician. The resident, who was admitted with multiple diagnoses including type 2 diabetes and heart disease, was identified as being at risk for pressure ulcers and had a stage 3 pressure ulcer on the coccyx. Despite having physician orders to cleanse the sacrum and apply specific dressings daily, the Treatment Administration Record (TAR) and Progress Notes indicated that wound care was not performed on two specific days. Additionally, the facility did not implement the wound care physician's recommendations for the resident, which included administering a multivitamin, Vitamin C, and Zinc Sulphate. The Licensed Practical Nurse (LPN) responsible for wound care admitted to not checking the wound care physician's notes for new orders, which resulted in the omission of these supplements from the resident's care plan. The Director of Nursing (DON) confirmed that the wound care nurse did not follow through with the physician's recommendations and acknowledged the lack of documentation for the days when wound care was not performed. The facility's policy required wound care procedures to be performed according to physician orders and documented in the clinical record. However, the failure to adhere to these protocols led to a deficiency in the care provided to the resident, as evidenced by the lack of wound care on specified days and the omission of recommended supplements from the resident's treatment plan.
Inadequate Dialysis Care and Communication Failures
Penalty
Summary
The facility failed to maintain effective communication and collaboration with a dialysis center, resulting in inadequate treatment and monitoring for two residents requiring dialysis care. Resident #3, diagnosed with end-stage renal disease and rapidly progressive nephritic syndrome, did not receive the prescribed medication Sevelamer Carbonate consistently due to a lack of availability from the pharmacy and dialysis center. Despite multiple notifications to the physician and attempts to contact the pharmacy and dialysis center, the medication was not administered as ordered, and there was a lack of documentation regarding the communication efforts and medication administration. Resident #4, diagnosed with acute kidney failure and undergoing hemodialysis, experienced issues with the dialysis transfer process. The resident's dialysis transfer forms were incomplete, lacking post-dialysis treatment information, and there was no documentation of vital signs or assessments in the electronic medical record after dialysis sessions. Additionally, the resident did not receive breakfast or snacks before dialysis, and there was a noted issue with transportation, leading to a late arrival for treatment and an abbreviated session. The facility's Director of Nursing and Unit Manager acknowledged the communication and documentation lapses, including the failure to document communication with the dialysis center and the absence of completed dialysis transfer forms. The facility's agreement with the dialysis center required immediate communication of changes in a resident's medical condition and the use of a Dialysis Communication Form, which was not consistently adhered to, contributing to the deficiencies in care for the residents.
Medication Administration Documentation Failure
Penalty
Summary
The facility failed to accurately document the administration of medications in the Medication Administration Record (MAR) for a resident with end-stage renal disease (ESRD) and rapidly progressive nephritic syndrome. The resident was prescribed Sevelamer Carbonate to be administered before meals, but the MAR showed discrepancies in the administration times and dates. Despite the medication being unavailable due to pharmacy delays, the MAR inaccurately recorded that the medication was administered on several occasions. Progress notes indicated ongoing communication issues with the pharmacy and dialysis center regarding the availability of Sevelamer. The Transitional Care Unit Manager acknowledged the medication was not available and that documentation was lacking. The Director of Nursing expected accurate documentation and communication with physicians, but admitted to not documenting all conversations. The facility's policy required accurate and accessible medical records, which was not adhered to in this case.
Infection Control Deficiency: Improper Handling of Soiled Linens
Penalty
Summary
The facility failed to adhere to proper infection control practices, specifically in hand hygiene and the use of personal protective equipment (PPE), when handling soiled linens. On the morning of February 12, 2025, a Certified Nursing Assistant (CNA) was observed leaving a resident's room with a bag of dirty linens while wearing a glove on her right hand. The CNA then entered another resident's room, interacted with the resident, and handled hospital gowns without changing gloves or performing hand hygiene. The CNA acknowledged these actions and admitted to not following proper procedures due to time constraints and workload, as she was responsible for preparing 12 residents for therapy and appointments. The Director of Nursing confirmed that the CNA's actions were not in compliance with the facility's infection control policy, which mandates that soiled linens should not be brought into another resident's room and that gloves should not be worn in the hallway. The facility's policy emphasizes hand hygiene as the primary means of preventing infection transmission and requires the removal and disposal of PPE before leaving a resident's room. Despite having completed infection control training, the CNA did not adhere to these protocols, leading to the identified deficiency.
Failure to Include Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident was offered participation in the development or revision of their care plan. The resident, a female with a history of malnutrition, type 2 diabetes, adjustment disorder with anxiety and depression, and a feeding tube, was readmitted to the facility from an acute care hospital. Despite her moderate cognitive impairment and moderate depression, the resident expressed a strong desire to have her feeding tube removed and to be discharged from the facility. However, she was not kept informed about the status of her feeding tube removal, leading to her visible distress. The facility's MDS Coordinator acknowledged that a care plan meeting was initially scheduled but was missed due to the resident's discharge to the hospital. Upon her return, the meeting was not rescheduled, resulting in the resident and her representative not being included in the care planning process. The Director of Nursing emphasized the importance of these meetings for ensuring that residents and their representatives understand the care and discharge plans, and for addressing any changes in the resident's condition or preferences. The facility's guidelines require that care plans be developed in consultation with the resident and their representative, which was not adhered to in this case.
Neglect Leads to Resident Elopement
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not ensuring staff maintained a secure environment and implemented measures to mitigate the risks to prevent elopement. This failure resulted in the elopement of a severely cognitively impaired resident who exited the facility unnoticed and unsupervised. The resident, who had a history of dementia and other mental health issues, was able to leave the facility and walk approximately 1.1 miles away before being noticed by an off-duty staff nurse. The resident had a care plan in place for potential elopement due to behaviors such as wandering and exit-seeking, and was supposed to be wearing an electronic wander monitoring bracelet. However, the facility did not adequately supervise the resident or ensure the bracelet was functioning properly. The resident had previously removed the bracelet, and despite escalating exit-seeking behaviors in the days leading up to the elopement, no additional interventions were added to the care plan. On the day of the incident, the facility's Weekend Supervisor unlocked the door for a visitor to leave and failed to notice the resident following behind. The resident exited the facility and was unsupervised for approximately 30 minutes. The facility's lack of adequate supervision and failure to update the resident's care plan with effective interventions contributed to the resident's elopement and placed him at risk for serious harm.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to maintain a secure environment and provide adequate supervision, resulting in a severely cognitively impaired resident exiting the facility unauthorized and unsupervised. The incident occurred when the Weekend Supervisor unlocked the door for a visitor and did not ensure that no residents followed. The resident, who had severe cognitive impairment and was at risk for elopement, exited the facility unnoticed and was outside for approximately 45 minutes, traveling over a mile away. The facility was unaware of the resident's absence until an off-duty staff member spotted him and notified the supervisor. The resident had a history of wandering and exit-seeking behaviors, which were documented in his care plan. Despite these known behaviors, the facility did not provide adequate supervision or update the care plan with additional interventions when the resident's behaviors escalated. The resident had previously removed his electronic wander monitoring bracelet, indicating a need for increased supervision, but this was not adequately addressed by the facility. Staff interviews revealed that the resident had been exhibiting increased exit-seeking behaviors on the day of the incident, yet the facility did not implement one-to-one supervision or other necessary interventions. The Weekend Supervisor, who was responsible for monitoring the resident, was unaware of his exit-seeking behavior and did not notice when he left the facility. This lack of awareness and supervision contributed to the resident's elopement and placed him at risk for serious harm.
Inadequate Investigation of Resident Elopement
Penalty
Summary
The facility failed to conduct a thorough investigation following the elopement of a resident with severe cognitive impairment. The resident, who had a history of dementia and other mental health disorders, was able to leave the facility unnoticed after following a visitor out the door. The incident was only discovered when an off-duty nurse reported seeing the resident walking along a busy highway. Video footage confirmed the resident's exit and return to the facility, but the facility's response to the incident was inadequate. Interviews with staff revealed that the resident had been exhibiting increased anxiety and wandering behavior on the day of the elopement. Despite these behaviors, the resident was not placed under one-to-one supervision. Staff members, including CNAs and LPNs, were aware of the resident's behavior but did not take sufficient action to prevent the elopement. The facility's investigation into the incident was incomplete, as not all staff members were interviewed, and some statements were inconsistent with the video evidence. The facility's policy on abuse, neglect, and investigation requires thorough interviews and documentation, which were not adequately followed. The Director of Nursing and other administrative staff failed to clarify or seek additional information from staff whose statements were vague or incorrect. The lack of documentation and follow-up interviews indicates a failure to properly investigate the incident and ensure the safety of the resident.
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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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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 Del Mar Health And Rehabilitation Center | 1.5 mi | ★★★★★ | 16 | 1 |
| Sunrise Point Health And Rehabilitation Center | 6.3 mi | ★★★★★ | 2 | 2 |
| Rockledge Healthcare & Rehabilitation Center | 6.6 mi | ★★★★★ | 0 | 0 |
| The Terrace At Courtenay Springs | 7 mi | ★★★★★ | 5 | 0 |
| Nursing & Rehabilitation Center Of Melbourne | 8.3 mi | ★★★★★ | 13 | 0 |
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