Inspection Reports for Veranda Rehabilitation and Healthcare

The facility failed to ensure that one of four medication carts was secured by a lock when left unattended, posing a risk of medication being accessed by unauthorized individuals. Interviews with staff confirmed expectations for locking medication carts and identified a lapse in securing the cart after an auditor's use.

The complaint investigation was substantiated regarding financial exploitation of Resident #39 by a former ABOM who withdrew funds without consent on 18 occasions totaling $4,671.22. The facility reimbursed the resident and involved law enforcement. Additional complaints related to care planning, infection control, and pest control were also investigated.

The facility was found to have failed to protect a resident from financial exploitation by a former employee, failed to develop and implement comprehensive person-centered care plans for two residents, failed to ensure proper labeling of intravenous dressings for infection control, and failed to maintain an effective pest control program in the kitchen.

The complaint was substantiated. The former ABOM admitted to unauthorized withdrawals from Resident #39's bank account and was arrested. The facility reimbursed the resident and implemented corrective measures including staff training and securing financial records.

The facility failed to protect Resident #39 from financial exploitation by the former ABOM, who withdrew $4,671.22 from the resident's bank account without consent on 18 occasions between October 2024 and March 2025. The facility reimbursed the resident and took corrective actions including staff in-service training and securing residents' financial information.

The complaint investigation revealed that the facility did not follow up on psychiatric consultation orders for Resident #1 and Resident #2, and Resident #3 did not receive eye drops as prescribed. The social worker responsible for psychiatric referrals did not carry out orders and no psychiatric consultations were documented. Medication administration errors were linked to unclear or conflicting orders from multiple clinics and resident resistance to providing post-visit orders.

The facility failed to ensure two residents received timely psychiatric consultations as ordered, and one resident did not receive prescribed eye drops at the correct frequency. These failures posed risks to residents' behavioral health and medication efficacy but were determined to have caused minimal harm.

The facility failed to maintain complete and accessible medical records for Resident #11 regarding DNR status, and failed to properly implement infection prevention and control practices for Residents #78 and #241, including improper equipment disinfection and inadequate PPE use during device care.

The complaint investigation focused on Resident #11's missing OOH-DNR form despite documented DNR status. Interviews with family members, nursing staff, social workers, medical records clerk, and administration revealed confusion and procedural issues in obtaining, verifying, and maintaining the DNR documentation. The family member confirmed signing a DNR form at the hospital, but the facility required a separate OOH-DNR form. The facility found the hard copy of the DNR form after searching old medical records.

The facility failed to maintain complete and accessible medical records for Resident #11's code status, as the OOH-DNR form was missing from the resident's medical record despite orders indicating DNR status. Interviews revealed procedural gaps in handling and verifying DNR documentation, and the facility policy on Advance Directives was reviewed.

The facility failed to ensure residents had reasonable accommodation of needs, specifically a call light within reach for Resident #2, and failed to provide adequate supervision and accident prevention measures for Resident #1 who eloped from the facility. The facility implemented corrective actions after the incidents.

The complaint investigation focused on the failure to report an injury of unknown origin involving Resident #22 within the required 2-hour timeframe. The facility self-reported the incident more than 24 hours after the fall. Interviews with LVN D, DON, Administrator, and other staff revealed delays and misunderstandings about reporting responsibilities and timelines. Resident #22 was cognitively impaired and unable to provide details about the fall. The facility policy required immediate reporting of such incidents.

The facility failed to report within the required 2-hour timeframe an incident involving Resident #22 who was found on the floor with a hematoma and purple discoloration, later diagnosed with a subarachnoid hemorrhage. Interviews with staff revealed confusion and delay in reporting to state agencies. Additionally, the facility failed to ensure Resident #51's environment was free from accident hazards by allowing a multiple blade razor to remain unsecured in his room.

The complaint investigation focused on the failure to report injuries of unknown origin involving Resident #22 within the required 2-hour timeframe. The facility self-reported the incident more than 24 hours after it occurred. Interviews with staff including LVNs, the Director of Nursing, Administrator, and Maintenance Director revealed confusion and delays in reporting. Resident #22 was cognitively impaired and unable to verbalize the incident. The facility policy required immediate reporting of such incidents, which was not followed.

The facility failed to report within the required 2-hour timeframe an incident where Resident #22 was found on the floor with a hematoma and purple discoloration, resulting in a subarachnoid hemorrhage. Additionally, the facility failed to ensure the resident environment was free from accident hazards, as Resident #51 was found to have a multiple blade razor in his room without proper care planning or supervision.