Viera Del Mar: Incomplete Discharge Records - FL
Resident #2 had been readmitted to the facility with a nontraumatic subacute subdural hemorrhage, chronic obstructive pulmonary disease, type 2 diabetes, repeated falls, speech and language deficits, and difficulty walking. Despite these serious conditions, his July 6 discharge summary was riddled with gaps.
The discharge form instructed staff to attach a copy of the medication list, enter pharmacy details, and document whether prescriptions were provided. None of this happened.
Several entire sections remained blank or unanswered: Skin Evaluation, Treatments, Cognitive/Psychosocial, Activities of Daily Living, Functional Status, Sensory, Dietary, Rehabilitation Services, and Education/Acknowledgement. The Instructions After Discharge section was only partially completed.
No evidence existed that a copy of the discharge summary was given to the resident. Neither the resident nor staff signed the form. Inspectors found no medication reconciliation or confirmation that medications were provided when he left.
The resident was discharged home with his spouse and mother-in-law at 11:06 on July 6, though the discharge form didn't specify whether that was morning or evening.
A physician's order dated the next day instructed the facility to "Discharge patient home with home health PT/OT and Nursing." But progress notes from June and July contained no entries about discharge planning. No documentation existed regarding education provided to the family, what happened to his medications, or whether prescriptions were issued.
The documentation failures extended far beyond discharge day.
For weeks before he left, certified nursing assistants failed to document basic daily care. Activities of Daily Living tasks including dressing, personal hygiene, bladder and bowel management, eating and fluids were left blank across all three shifts for most of June and the first week of July.
On the day shift from 7 AM to 3 PM, ADL documentation was missing for 19 days between June 5 and July 6. The evening shift from 3 PM to 11 PM had blank entries for 16 days. The overnight shift from 11 PM to 7 AM missed documentation for 15 days.
The gaps weren't isolated incidents. They occurred almost daily in the resident's final month at the facility, including his last day there.
When confronted by inspectors on September 9, the Director of Nursing acknowledged the problems. At 12:44 PM, she said her expectation was that certified nursing assistants document care before leaving the facility and as close as possible to when care was performed. She explained nurses should document assessments and progress notes before a resident's discharge.
Two hours later, the Director of Nursing admitted she wasn't working at the facility during the resident's stay. "I understand what you mean," she said about the blanks in documentation. She acknowledged the discharge summary was incomplete and unsigned.
The facility's own medical records policy, revised in January 2024, requires that "Medical Records will be maintained within the facility per federal requirements."
Federal regulations mandate that nursing homes maintain complete medical records using accepted professional standards. The records must accurately document each resident's care and condition.
For a resident with multiple serious conditions including a brain bleed, the missing documentation created significant safety risks. Without proper medication reconciliation, he could face dangerous drug interactions or missed doses at home. The blank ADL assessments meant his family received no information about his actual functional abilities or care needs.
The incomplete discharge planning was particularly concerning given his diagnoses. Speech and language deficits, abnormalities of gait and mobility, and difficulty walking required specific instructions for home care. His repeated falls history demanded detailed safety planning.
His quarterly assessment in May had noted an active discharge plan for return to the community. The July discharge assessment indicated a planned discharge home with return not anticipated, suggesting this was intended as a permanent transition.
But the facility failed to provide the basic documentation required for safe community transition. The blank medication sections alone violated fundamental discharge safety protocols.
The resident's case illustrates how documentation failures can compromise patient safety even when the intent is discharge to a less restrictive setting. Without complete records, families and home health providers lack essential information about medications, functional status, and care requirements.
The inspection found that certified nursing assistants routinely left care documentation blank, suggesting systemic problems beyond this single resident's experience.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Viera Del Mar Health and Rehabilitation Center from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
VIERA DEL MAR HEALTH AND REHABILITATION CENTER in VIERA, FL was cited for violations during a health inspection on September 9, 2025.
Despite these serious conditions, his July 6 discharge summary was riddled with gaps.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.