Viera Del Mar Health And Rehabilitation Center

F 0641

Ensure each resident receives an accurate assessment.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected prescribed medications for 1 of 2 residents reviewed for behaviors, of a total sample of 12 residents, (#2).Findings: Review of resident #2's medical record revealed she was readmitted to the facility from an acute care hospital on 8/20/25. Her diagnoses included multiple sclerosis, major depressive disorder, anxiety and seizures. Additional diagnoses of bipolar disorder, brief psychotic disorder, and psychosis were added after resident #2's readmission on [DATE REDACTED]. 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.

Residents Affected - Few

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

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Del Mar Health and Rehabilitation Center

2355 Vidina Drive Viera, FL 32940

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0646 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

(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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Del Mar Health and Rehabilitation Center

2355 Vidina Drive Viera, FL 32940

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident #12 frequently requested pain medication and that nurses occasionally became frustrated with repeated requests. She concluded, Not answering call lights in a timely manner could be considered neglect. On 10/24/25 at 5:19 PM, during a telephone interview, CNA F reported at times only one CNA was assigned to a unit during the 11:00 PM - 7:00 AM shift. She noted delays occurred due to having to locate supplies and the need for two staff to assist residents with transfers. When asked if she had mentioned her concerns to management, she responded she had not because management must be aware of staffing shortages. CNA F stated assisting with dining room service was difficult as it would leave only one CNA on

the unit for up to two hours. On 10/24/25 at 2:18 PM, during an interview with the Administrator (NHA) and

the Director of Nursing (DON), the NHA stated resident #12 frequently activated his call light immediately

after staff left his room. The DON described the resident as drug seeking and clarified that while scheduled pain medications could be given one hour early or late, PRN medication could not be administered sooner than prescribed. Both the NHA and DON acknowledged expectations for timely call light response. The NHA confirmed residents had voiced staffing concerns during Resident Council meetings but stated she and the DON had made rounds on evening and weekends without noting issues. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Viera Del Mar Health and Rehabilitation Center

2355 Vidina Drive Viera, FL 32940

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880

Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to follow appropriate hand hygiene and personal protective equipment (PPE) practices in accordance with infection control standards when assisting a resident with an intravenous (IV) infusion for 1 of 1 residents observed during the facility tour, from a total sample of 12 residents, (#5).Findings: Review of resident #5's medical record revealed she was admitted to

the facility on [DATE REDACTED] with diagnoses including metabolic encephalopathy (brain dysfunction), type 2 diabetes, stroke, anemia, and weakness. 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.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet