Viera Del Mar Health And Rehabilitation Center
VIERA DEL MAR HEALTH AND REHABILITATION CENTER in VIERA, FL — inspection on October 24, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of resident #2's significant change in status MDS assessment with an Assessment Reference Date (ARD) of 9/11/25 revealed she received high-risk medications classified as anticonvulsants and antibiotics during the 7-day look back period.
Review of resident #2's medical record revealed physician's orders for Venlafaxine 150 milligrams (mg) daily for depression, Cephalexin 500 mg twice daily for urinary tract infection, Divalproex 250 mg every 12 hours for bipolar disorder, Haloperidol 5 mg twice daily for behavioral disorder, Lacosamide 200 mg twice daily for seizures, Lamotrigine 200 mg twice daily for seizures, Quetiapine 50 mg three times daily for psychosis, Seroquel 75 mg every eight hours for brief psychosis, and Oxycodone-Acetaminophen 5-325 mg every eight hours as needed (PRN) for non-acute pain.
Review of the Medication Administration Report (MAR) for September 2025 revealed resident #2 received Venlafaxine, Cephalexin, Divalproex, and Lamotrigine from 9/07/25 to 9/11/25.
She also received Haloperidol from 9/07/25 to 9/09/25, Lacosamide from 9/08/25 to 9/11/25, Quetiapine from 9/08/25 to 9/10/25, Seroquel on 9/10/25 and 9/11/25, and Oxycodone-Acetaminophen on 9/08/25.
Review of Section N - Medications of the MDS assessment indicated the form required documentation of 11 drug classes by use and indication.
The instructions directed staff to mark the box if the resident received medications within the pharmacological classification during the last seven days, or since admission or reentry if less than seven days. On 10/23/25 at 2:42 PM, the MDS Lead reviewed resident #2's significant change in status MDS assessment with an ARD of 9/11/25 alongside the September MAR.
She confirmed section N should have included antipsychotic, antidepressant, and opioid medications.
She explained MDS staff reviewed the MAR to determine which medications a residents received during the lookback period, using the Resident Assessment Instrument (RAI) as a guide.
The MDS Lead stated the assessment was completed by a new MDS Coordinator and corporate audits were performed but only on a random basis.
She acknowledged the expectation was for all MDS assessments to be accurate.
Review of the facility's Comprehensive MDS Assessment and Care Plan policy, revised February 2024, revealed the facility would complete the comprehensive assessment using the RAI specified by the Centers for Medicare & Medicaid Services.
The policy read, The facility will conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity initially and periodically.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Viera Del Mar Health and Rehabilitation Center
2355 Vidina Drive Viera, FL 32940
SUMMARY STATEMENT OF DEFICIENCIES
(SSD). On 10/23/25 at 8:53 PM, during a telephone interview, Registered Nurse (RN) C reported caring for resident #2 the night she was [NAME] Acted.
She described the resident as out of control, screaming, crying, throwing objects, removing clothes, defecating, urinating on the floor, and refusing food and fluids.
She confirmed APRN K ordered the hospital transfer under a [NAME] Act. On 10/23/25 at 4:20 PM, the DON explained new admissions were reviewed by the interdisciplinary team the next business day, including PASARR documentation received from the hospital.
She stated the SSD or DON was responsible for reviewing the PASARR and one should be completed when a new SMI diagnosis or behavioral changes occurred.
The DON acknowledged a new PASARR was not completed despite significant behavioral changes during resident #2's stay. On 10/24/25 at 1:30 PM, the Administrator (NHA) stated resident #2 had an extensive psychiatric history and was followed closely by psychiatric providers.
The NHA confirmed documentation showed resident #2 exhibited delusions, including claims of giving birth in the facility.
The NHA validated the PASARR was not resubmitted, calling it an oversight. On 10/24/25 at 2:18 PM, the Regional Nurse Consultant (RNC) stated residents receiving psychotropic medications were followed by psychiatric providers.
The RNC acknowledged the PASARR should have been reviewed but opined that a Level II may not have been issued even if resubmitted. On 10/24/25 at approximately 2:45 PM, the NHA stated the facility did not have a policy defining which staff member was responsible for updating PASARRs.
A copy of the facility's policy regarding Behavioral Health or Behavior Management was requested but not provided.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Viera Del Mar Health and Rehabilitation Center
2355 Vidina Drive Viera, FL 32940
SUMMARY STATEMENT OF DEFICIENCIES
Review of the facility's Call lights policy and procedure, revised January 2024, read, Resident will have a call light to summon facility personnel to ensure the resident's needs will be met.
The Procedure required staff to Answer call light promptly.
All facility personnel are expected to respond to call light.
Listen to resident's request. DO NOT make residents feel that you are too busy.
Respond to resident's request, if unable to assist, notify the nurse.
Return to the resident promptly with a reply.
Review of the Facility Assessment, approved by the Quality Assurance and Performance Improvement committee on 10/14/25, revealed its purpose was to determine the resources necessary to provide competent resident care using a competency-based approach.
The assessment identified staffing levels based on resident population, acuity, and care needs, and read, Staffing is adjusted to meet the needs of current population and resident needs.
Data showed the following number of residents required staff assistance with ADLs:Dressing 1-2 staff: 93 residents dependent: 26 residentsBathing 1-2 staff: 93 residents dependent: 29 residentsTransfer 1-2 staff: 74 residents dependent: 36 residentsEating 1-2 staff: 97 residents dependent: 4 residentsToileting 1-2 staff: 75 residents dependent: 41 residents The assessment emphasized timely response to ADL and toileting needs to maintain continence, dignity, and person-centered care.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/24/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Viera Del Mar Health and Rehabilitation Center
2355 Vidina Drive Viera, FL 32940
SUMMARY STATEMENT OF DEFICIENCIES
Review of resident #5's comprehensive care plan identified a focus area related to a midline catheter in the right upper extremity for treatment of anemia.
The goal of the care plan was for the resident to experience no complications associated with the IV access or its use through the next review date. On 10/23/25 at 12:09 PM, Licensed Practical Nurse (LPN) G exited resident #5's room wearing gloves on both hands.
While outside the resident's room, LPN G used scissors from the medication cart to open an IV-line package, then reentered the room.
Inside the room, LPN G connected the IV line to a medication pouch on the IV pole, pulled a garbage can closer to her and the IV pole and continued setting up the IV tubing to begin an iron infusion.
After several minutes working with the IV machine, LPN G informed resident #5 she needed to step out to obtain assistance. On 10/23/25 at 12:15 PM, LPN G confirmed she had exited resident #5's room without removing her gloves or performing hand hygiene and then returned to the room wearing the same gloves.
She validated she moved the trash can wearing the same gloves and resumed working with the IV line. LPN G stated she was in a rush because the resident was waiting on her to finish setting up the infusion to eat her lunch.
She acknowledged her actions violated infection control protocol and placed resident #5 at risk for infection. On 10/24/25 at approximately 2:20 PM, the Director of Nursing (DON) stated staff were expected to remove gloves before exiting a resident's room and perform hand hygiene immediately afterward.
The DON added, Obviously, the nurse knew it was incorrect.
Review of the Facility Assessment, updated on 10/06/25, revealed all staff received infection control and hand hygiene education upon hire and annually thereafter.
Facility ID: