The resident, identified only as #2 in inspection records, was readmitted to Viera Del Mar Health and Rehabilitation Center from a hospital on August 20, 2025. Her medical record showed diagnoses of multiple sclerosis, major depressive disorder, anxiety and seizures. After readmission, staff added bipolar disorder, brief psychotic disorder, and psychosis to her conditions.
Federal inspectors found the facility's MDS coordinator failed to document three entire classes of medications the resident received daily during September 2025. The Minimum Data Set assessment, completed with a reference date of September 11, serves as the foundation for care planning and determines Medicare payment rates.
According to physician orders, the resident received a complex medication regimen. She took Venlafaxine 150 milligrams daily for depression, Divalproex 250 milligrams every 12 hours for bipolar disorder, and Haloperidol 5 milligrams twice daily for behavioral issues. Additional psychiatric medications included Quetiapine 50 milligrams three times daily for psychosis and Seroquel 75 milligrams every eight hours for brief psychosis.
The medication administration records confirmed she received these drugs during the seven-day assessment period. From September 7 through September 11, she took Venlafaxine and Divalproex daily. She received Haloperidol from September 7 through September 9, Quetiapine from September 8 through September 10, and Seroquel on September 10 and 11.
Yet none of these psychiatric medications appeared on her MDS assessment.
The MDS Lead acknowledged the errors during an interview with inspectors on October 23. She confirmed that Section N of the assessment should have included antipsychotic, antidepressant, and opioid medications. The resident had also received Oxycodone-Acetaminophen on September 8, which was similarly omitted.
"MDS staff reviewed the MAR to determine which medications a residents received during the lookback period, using the Resident Assessment Instrument as a guide," the MDS Lead explained to inspectors. She stated the assessment was completed by a new MDS Coordinator.
The facility's own policy, revised in February 2024, requires staff to "conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity." The policy specifically references using the Resident Assessment Instrument specified by the Centers for Medicare & Medicaid Services.
Federal regulations require nursing homes to mark medication boxes if residents received drugs within specific pharmacological classifications during the previous seven days. The instructions are explicit: facilities must document 11 drug classes by use and indication.
The MDS Lead told inspectors that corporate audits were performed "only on a random basis." She acknowledged "the expectation was for all MDS assessments to be accurate."
The omissions are particularly significant for a resident managing multiple psychiatric conditions simultaneously. The assessment inaccuracies could affect care planning decisions and federal reimbursement calculations.
The resident also received seizure medications during the assessment period. Records showed she took Lacosamide 200 milligrams twice daily and Lamotrigine 200 milligrams twice daily for seizures, along with Cephalexin 500 milligrams twice daily for a urinary tract infection.
Inspectors found the facility failed to ensure accurate assessments for one of two residents they reviewed for behavioral issues, out of a total sample of 12 residents examined during the complaint investigation.
The deficiency was classified as causing minimal harm or potential for actual harm to residents. Federal inspectors noted that few residents were affected by the assessment failures.
The inspection occurred on October 24, 2025, following a complaint about the facility's assessment practices. The findings revealed systematic gaps in medication documentation that could compromise both care coordination and federal oversight of prescription drug use in nursing homes.
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 2025-10-24 including all violations, facility responses, and corrective action plans.
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