Viera Del Mar Health And Rehabilitation Center

Review of resident #2's quarterly Minimum Data Set (MDS) assessment with Assessment Reference Date (ARD) of 5/11/25 revealed the resident participated in the assessment, and there was an active discharge plan for return to the community.

Review of the Discharge MDS assessment with ARD of 7/06/25 revealed a planned discharge home, return not anticipated.

Review of resident #2's medical record revealed a Discharge Summary form with an effective date of 7/06/25 at 11:06 (time of day was not specified).

The Summary of Stay section indicated the resident was discharged home with his spouse and mother-in-law.

The resident status was listed as long term care.

Several sections of the discharge form were left blank or unanswered, including Skin Evaluation, Treatments, Cognitive/Psychosocial, ADLs (Activities of Daily Living)/Functional Status, Sensory, Dietary, Rehabilitation Services, and Education/Acknowledgement.

The Instructions After Discharge section was only partially completed.

The Medications and Treatments questions were unanswered.

The form instructed staff to **ATTACH COPY OF MEDICATION LIST**, enter pharmacy details, and document whether scripts were provided.

These were not addressed and not documented.

There was no evidence in the record that a copy of the Discharge Summary was given to resident #2, nor was it signed by the resident or staff.

There was also no evidence of a medication reconciliation or confirmation that medications were provided upon discharge.

Review of resident #2's physician orders revealed an order dated 7/07/25 and read, Discharge patient home with home health PT/OT (Physical Therapy/Occupational Therapy) and Nursing.

Review of June and July 2025 Progress Notes did not reveal any entries regarding discharge planning. No documentation was found regarding education provided, disposition of medications, or scripts issued when the resident left.

Review of resident #2's Documentation Survey Report for June 2025 and July 2025, which showed ADL tasks such as dressing, personal hygiene, bladder and bowel, eating and fluids documented by the Certified Nursing Assistant (CNAs) were left blank on the following shifts: 7 AM to 3 PM - 6/5, 6/7, 6/8, 6/9, 6/11, 6/12, 6/13, 6/17, 6/21, 6/22, 6/23, 6/25, 6/27, 6/28, 6/29, 7/3, 7/4, 7/5, 7/6 3 PM - 11 PM - 6/7, 6/12, 6/14, 6/15, 6/19, 6/20. 6/21, 6/23, 6/25, 6/28, 6/29, 6/30, 7/2, 7/5, 7/6 11 PM - 7 AM - 6/5, 6/7, 6/9, 6/13, 6/14, 6/20, 6/21, 6/22, 6/26, 6/29, 6/30, 7/3, 7/4, 7/5, 7/6 On 9/09/25 at 12:44 PM, the Director of Nursing (DON) shared her expectation was that CNAs documented the care they provided to the residents prior to leaving the facility and as close as possible to the time the care was performed.

She explained nurses were to document their assessments and progress notes before a resident left the facility.

Later at 2:00 PM, the DON stated she was not working in the facility at the time but responded, I understand what you mean, in regard to the blanks in staff's documentation for resident #2.

She acknowledged the Discharge Summary was incomplete and unsigned.

Review of the facility's Medical Records policy and procedure revised in January 2024 read, Medical Records will be maintained within the facility per federal requirements.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Del Mar Health and Rehabilitation Center

2355 Vidina Drive Viera, FL 32940

SUMMARY STATEMENT OF DEFICIENCIES

Based 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.

Findings:

Review of the facility's Quality Assurance and Performance Improvement (QAPI) Program policy, undated revealed objectives which included to Establish systems through which to monitor and evaluate corrective actions.

The Implementation section described the process in which the QAPI plan identified and corrected deficiencies.

The key components included developing and implementing corrective action or performance improvement activities and monitoring or evaluating the effectiveness of the corrective action, revising when necessary.

The facility had deficiencies at F-F842 in complaint surveys conducted on 12/14/23 and 10/16/24 for non-compliance with the medical record and accuracy of documentation.

Review of the Statement of Deficiencies and Plan of Correction form for the survey conducted on 12/14/23 revealed a Plan of Correction was completed on 1/19/24.

The facility documented education to the nursing staff on the components of F-F842, resident records, and accuracy of documentation was performed.

Review of the Statement of Deficiencies and Plan of Correction form for the survey conducted on 10/16/24 revealed a Plan of Correction was completed on 11/22/24.

The facility again documented education was provided to the current nursing staff and newly hired nurses on the components of F-F842.

The Plan of Correction indicated audits were to be performed until compliance was reached.

During this survey, deficiencies were again identified at F-F842, for resident records and accuracy of documentation. As a result of the repeated citation, it was identified there was insufficient auditing and oversight by the QAPI team to prevent repeated deficiencies. On 9/09/24 at 5:15 PM, the Administrator (NHA) stated she had attended two QAPI meetings since starting to work in the facility in mid-July 2025.

She explained during the QAPI meeting, they reviewed processes relevant to each department to ensure no deficiencies or concerns with deviations from their policy were identified.

She indicated when issues were identified, they worked with their corporate team to develop and implement a Performance Improvement Plan.

The NHA stated she was not aware of the previous deficiencies regarding medical records documentation.

Facility ID: