Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than Florida average
Florida average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 4, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to refund a resident's positive account balance within 30 days of discharge.
Complaint Details
The complaint was substantiated based on interviews and record review showing the facility did not refund the resident's positive balance within the required timeframe despite multiple requests and acknowledgment by facility staff.
Findings
The facility failed to refund resident #151 or her representative the positive balance of $517.06 within 30 days after discharge. Multiple attempts by the resident's guardian to obtain the refund were unsuccessful, and facility staff acknowledged the outstanding balance and delay in refund issuance.
Deficiencies (1)
Failure to refund to the resident or resident representative any and all refunds due within 30 days from the resident's date of discharge.
Report Facts
Positive balance amount: 517.06
Resident sample size: 49
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannelle [NAME] | Guardian, Durable Power of Attorney (Financial) | Resident #151's guardian who requested refund and communicated with facility. |
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 12
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including resident rights, care planning, personal funds management, environment cleanliness, grievance handling, restorative services, respiratory care, and food safety.
Findings
The facility was found deficient in multiple areas including failure to promote resident dignity during dining, inadequate response to resident council grievances, improper management of resident personal funds, unsanitary conditions in shower rooms and kitchen, failure to follow grievance procedures, incomplete care plans for residents with mental health diagnoses, insufficient assistance with activities of daily living, lack of implementation of restorative nursing program, failure to obtain physician orders for respiratory treatments, and failure to provide trauma-informed care. Repeat deficiencies indicated insufficient quality assurance oversight.
Deficiencies (12)
Failed to promote dignity during dining for a resident dependent on staff for meals, with staff standing while feeding due to lack of chair and no documentation of resident preference.
Failed to respond in writing to repeated grievances identified by resident council over six months regarding staffing, customer service, and dietary issues.
Failed to properly hold, secure, and manage resident personal funds, including failure to provide quarterly financial statements to resident or Power of Attorney.
Failed to maintain sanitary, orderly, and comfortable interior in shower rooms, with black substance on ceilings and vents, and lack of maintenance notification.
Failed to follow grievance process by not making prompt effort to resolve a resident's grievance regarding broken personal property and not keeping resident apprised of progress.
Failed to develop comprehensive person-centered care plans for residents with antipsychotic medications and serious mental illness diagnoses including paranoid schizophrenia.
Failed to ensure residents received proper and timely assistance with activities of daily living including oral care and showers, with documentation gaps and resident complaints of missed showers.
Failed to implement recommended Restorative Nurse Program to provide mobility and range of motion services as per therapy recommendations, with lack of documentation and care plan incorporation.
Failed to obtain physician orders for respiratory treatments including CPAP use, resulting in resident not using prescribed CPAP machine for several weeks after admission.
Failed to provide trauma-informed care for a resident with PTSD, including lack of care plan addressing trauma, triggers, and supportive interventions.
Failed to maintain overall cleanliness of the kitchen, including dirty floors, sticky residues, presence of ants, unclean containers, expired and improperly stored food items.
Failed to ensure Quality Assessment & Assurance committee conducted performance improvement activities to sustain prior improvement measures, resulting in repeat deficiencies.
Report Facts
Residents reviewed for dignity: 2
Total residents in sample: 49
Residents dependent on staff for eating: 25
Deficiency citations: 12
Resident #20 MDS BIMS score: 15
Resident #116 MDS BIMS score: 3
Resident #143 MDS BIMS score: 12
Resident #33 MDS BIMS score: 14
Date of survey completion: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA B | Certified Nursing Assistant | Named in dignity during dining deficiency for resident #20 |
| CNA C | Certified Nursing Assistant | Named in dignity during dining deficiency for resident #20 |
| LPN C | Licensed Practical Nurse | Named in dignity during dining deficiency for resident #20 |
| Unit Manager (UM) | Named in dignity during dining and shower assistance deficiencies | |
| Director of Nursing (DON) | Named in dignity during dining and shower assistance deficiencies | |
| Financial Specialist Assistant A | Named in personal funds management deficiency | |
| Financial Specialist Assistant F | Named in personal funds management deficiency | |
| Activity Director | Named in grievance handling deficiency | |
| Social Services Director (SSD) | Named in grievance handling and trauma-informed care deficiencies | |
| Nursing Home Administrator (NHA) | Named in grievance handling deficiency | |
| MDS Coordinator | Named in care planning deficiencies | |
| RNP nurse | Named in restorative nursing program deficiency | |
| Director of Therapy | Named in restorative nursing program deficiency | |
| CNA E | Certified Nursing Assistant | Named in respiratory care and shower assistance deficiencies |
| LPN D | Licensed Practical Nurse | Named in respiratory care and shower assistance deficiencies |
| Kitchen Manager | Named in kitchen sanitation deficiency | |
| Maintenance Director | Named in kitchen sanitation deficiency | |
| Administrator | Named in quality assurance deficiency |
Inspection Report
Routine
Deficiencies: 2
Date: Feb 6, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding dietary assessments and medical record maintenance at West Melbourne Health & Rehabilitation Center.
Findings
The facility failed to complete dietary assessments within the recommended 72-hour timeframe for 2 of 2 sampled residents and failed to obtain preferences and allergies related to lactose intolerance for 1 resident. Additionally, the facility failed to ensure complete and readily accessible medical records for all 16 sampled residents and failed to safeguard hard copy medical records properly.
Deficiencies (2)
Failed to complete dietary assessment within recommended timeframes for 2 residents and failed to obtain preferences and allergies pertaining to lactose intolerance for 1 resident.
Failed to ensure complete medical records were readily accessible and not restricted for 16 sampled residents and failed to safeguard hard copy medical records.
Report Facts
Residents affected: 2
Residents affected: 16
Hours late for dietary assessment: 96
Hours for dietary assessment completion: 72
Number of cardboard boxes: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Explained dietary assessment process and acknowledged failure to complete assessments timely | |
| Nursing Home Administrator (NHA) | Informed about incomplete medical records and access issues | |
| Director of Nursing (DON) | Acknowledged medical record access delays and issues with safeguarding | |
| Minimum Data Set (MDS) Coordinator | Reported limited access to electronic health records | |
| Medical Records Licensed Practical Nurse (LPN) | Reported restrictions on surveyor access to records and demonstrated storage conditions | |
| C Unit Manager | Explained CNA documentation access and EHR system usage | |
| Maintenance Director | Recalled request to repair lock on storage closet for medical records |
Inspection Report
Complaint Investigation
Deficiencies: 10
Date: Dec 14, 2023
Visit Reason
The inspection was conducted based on complaint investigations related to multiple care and compliance concerns at West Melbourne Health & Rehabilitation Center.
Complaint Details
The visit was complaint-related, investigating multiple allegations including failure to provide transfer/discharge notifications, inadequate care planning, improper ADL care, failure to follow leave of absence orders, improper infection control practices, and other care deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide timely written notification of resident transfer or discharge, failure to develop baseline care plans within 48 hours of admission, failure to involve residents in care plan meetings, inadequate provision of activities of daily living care, failure to follow physician orders for leave of absence monitoring, improper midline dressing changes, failure to administer oxygen therapy per physician orders, inadequate tracheostomy care and suctioning, lack of nursing staff competency for tracheostomy care, failure to maintain proper infection control practices including PPE use, and failure to operate dishwashing equipment at required temperatures.
Deficiencies (10)
Failed to provide written Notification of Transfer or Discharge forms to residents or their representatives for hospitalizations.
Failed to develop a baseline care plan within 48 hours of admission for pain management.
Failed to ensure residents were involved in developing the comprehensive person-centered plan of care.
Failed to provide fingernail care for a dependent resident.
Failed to ensure nurses followed physician's Leave of Absence orders and failed to provide necessary monitoring and supervision to mitigate risk of serious injury.
Failed to ensure a Midline dressing was changed in accordance with professional standards to prevent infection.
Failed to provide safe and appropriate respiratory care including tracheostomy care and suctioning, and failed to administer oxygen therapy per physician's order.
Failed to ensure nurses and nurse aides were competent to care for residents with tracheostomy.
Failed to ensure dishes were washed at the appropriate temperature according to the dish machine's data plate and manufacturer's instructions.
Failed to provide and implement an infection prevention and control program including proper PPE use for residents on transmission-based precautions.
Report Facts
Resident sample size: 52
Resident #5 sample size: 1
Resident #199 sample size: 1
Resident #52 sample size: 3
Resident #7 sample size: 3
Resident #77 sample size: 7
Resident #198 sample size: 1
Resident #40 sample size: 4
Resident #109 sample size: 1
Dish machine temperature: 156
Dish machine temperature: 155
Blood Alcohol Level: 0.1065
LOA sign outs: 42
LOA return times missing: 35
LOA return times recorded: 7
Pulse oximetry reading: 97
Heart rate: 120
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Named in transfer/discharge notification deficiency. |
| Medical Records clerk | Medical Records clerk | Named in transfer/discharge notification deficiency. |
| Director of Nursing | Director of Nursing (DON) | Named in transfer/discharge notification and respiratory care deficiencies. |
| Administrator | Administrator | Named in transfer/discharge notification deficiency. |
| Registered Nurse/ Minimum Data Set Coordinator | RN/MDS Coordinator | Named in baseline care plan and care plan participation deficiencies. |
| Registered Nurse/ Unit Manager | RN/UM | Named in care plan participation deficiency. |
| Certified Nursing Assistant F | CNA F | Named in ADL care deficiency. |
| Licensed Practical Nurse B | LPN B | Named in respiratory care and tracheostomy care deficiencies. |
| Licensed Practical Nurse A | LPN A | Named in respiratory care and tracheostomy care deficiencies. |
| Staff Development nurse | Staff Development nurse | Named in respiratory care and tracheostomy care deficiencies. |
| Licensed Practical Nurse K | LPN K | Named in leave of absence monitoring deficiency. |
| Licensed Practical Nurse G | LPN G | Named in IV fluid administration deficiency. |
| Regional Case Manager | Regional Case Manager | Named in baseline care plan and care plan participation deficiencies. |
| Physical Therapist D | Physical Therapist | Named in infection control PPE deficiency. |
| Certified Nursing Assistant I | CNA I | Named in infection control PPE deficiency. |
| Director of Nursing (DON) | Director of Nursing | Named in multiple deficiencies including respiratory care and infection control. |
| Assistant Director of Nursing (ADON) | Assistant Director of Nursing | Named in respiratory care and infection control deficiencies. |
| Respiratory Therapist | Respiratory Therapist (RT) | Named in respiratory care and tracheostomy care deficiencies. |
| Dietary Manager | Dietary Manager | Named in dishwashing temperature deficiency. |
| Dietary Aide L | Dietary Aide | Named in dishwashing temperature deficiency. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Named in leave of absence monitoring deficiency. |
| Primary Care Physician | Primary Care Physician | Named in leave of absence monitoring deficiency. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jun 15, 2023
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to inform a resident's representative of a change in condition related to a fall and pending x-ray for one of two residents reviewed for falls.
Complaint Details
The complaint investigation found that the facility did not notify resident #2's family of a fall and x-ray results in a timely manner. The Director of Nursing confirmed the failure to document family notification and the absence of incident/change in condition reports. The facility policy requires prompt notification of changes in condition to family/legal representatives.
Findings
The facility failed to promptly notify the resident's family about a fall and subsequent x-ray results. Documentation showed delays and missing incident/change in condition reports, and the Director of Nursing confirmed the lack of family notification contrary to facility protocol and policy requirements.
Deficiencies (1)
Failure to inform the resident representative of a change in condition related to a fall and pending x-ray for resident #2.
Report Facts
Residents reviewed for falls: 2
Total sample residents: 13
Falls sustained by resident #2: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided explanation about the falls and notification failures |
| former C-Wing Unit Manager | Unit Manager (UM) | Asked to enter the incident report due to assigned nurse no longer employed |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure effective communication and collaboration among the interdisciplinary team to provide necessary care and services, specifically related to the treatment and prevention of complications from urinary tract infections (UTIs) in a resident.
Complaint Details
The complaint investigation focused on resident #1 who had multiple UTIs and increased confusion. Labs ordered on 1/13/23 were not collected on 1/14/23 as required. The resident's condition worsened with lethargy, refusal of medications, and low oxygen saturation, leading to hospital transfer and diagnosis of sepsis. Family and staff interviews revealed missed communication and lack of follow-up on lab results. The facility acknowledged the missed labs but did not notify the physician or follow up appropriately.
Findings
The facility failed to follow physician orders and adequately treat a resident's change in condition related to a UTI, resulting in actual harm. Labs ordered for the resident were not collected as required, leading to delayed treatment and the resident developing sepsis and requiring hospitalization. The facility lacked proper follow-up and communication regarding the missed labs and the resident's worsening condition.
Deficiencies (1)
Failure to provide appropriate treatment and care according to orders, resulting in actual harm due to missed lab collections and delayed treatment of UTI leading to sepsis.
Report Facts
Date of lab order: Jan 13, 2023
Date lab specimen expected: Jan 14, 2023
Dates of vital signs documented: Vital signs documented on 1/2/23, 1/6/23, 1/16/23, and 1/23/23; no vital signs from 1/24/23 to 1/29/23
Date of hospital transfer: Jan 29, 2023
Number of residents reviewed for UTIs: 4
Total sample size: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| APRN C | Advance Practice Registered Nurse | Ordered labs for resident #1 and acknowledged treatment delay |
| Director of Nursing | Director of Nursing (DON) | Acknowledged missed labs and lack of follow-up for resident #1 |
| Licensed Practical Nurse B | Licensed Practical Nurse | Reported resident #1 had received IV antibiotics in the past and noted available practitioner and lab services |
| Medical Director | Medical Director | Resident #1's attending physician who commented on the missed follow-up and clinical implications |
| Unit Manager | Unit Manager (UM) | Explained specimen collection process and confirmed labs were not obtained for resident #1 |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Mar 16, 2022
Visit Reason
The inspection was conducted as part of the facility's annual recertification survey and to assess compliance with regulatory requirements including resident rights, environment, resident assessments, respiratory care, pain management, nutrition, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during incontinence care, maintain a safe and homelike environment, complete timely and accurate Minimum Data Set (MDS) assessments, provide activities consistent with resident preferences, administer oxygen as ordered, provide appropriate pain management, follow therapeutic diets, maintain clean garbage storage, and ensure proper maintenance of oxygen concentrator equipment. The facility also lacked effective Quality Assurance and Performance Improvement (QAPI) processes to address recurring deficiencies.
Deficiencies (12)
Failed to ensure resident dignity during incontinence care due to missing privacy curtain exposing resident.
Failed to maintain a clean, comfortable, and homelike environment in multiple resident rooms with damaged walls, flooring, and stained privacy curtains.
Failed to complete Annual and Significant Change in Status MDS assessments within 14 days of assessment reference date for 5 of 16 residents.
Failed to complete Quarterly MDS assessments within 14 days of assessment reference date for 7 of 16 residents.
Failed to transmit MDS assessments to CMS within 14 days of completion for 1 of 16 residents.
Failed to incorporate resident's expressed activity preferences into care plan and failed to ensure access to television to promote well-being.
Failed to administer oxygen as ordered by physician; oxygen flow rate was set higher than ordered for resident with tracheostomy.
Failed to provide pain management consistent with professional standards; pain assessments were not documented as ordered and pain levels were not consistently recorded.
Failed to follow and serve therapeutic diets as per facility's menu for residents on pureed and mechanical soft diets.
Failed to maintain garbage storage area in clean and sanitary condition; trash and debris were scattered and dumpster doors were left open.
Failed to ensure oxygen concentrator's external filter was clean and maintained to promote proper oxygen flow.
Failed to implement timely and appropriate Quality Assurance and Performance Improvement (QAPI) plans to address repeat deficiencies related to physical environment and MDS assessments.
Report Facts
Residents reviewed for dignity: 5
Total sample of residents: 56
Residents with delayed Annual and Significant Change MDS assessments: 5
Residents with delayed Quarterly MDS assessments: 7
Residents with delayed MDS transmission: 1
Residents on pureed diets: 13
Residents reviewed for respiratory care: 5
Residents reviewed for pain management: 2
Residents affected by garbage storage deficiency: Many
Residents affected by QAPI deficiency: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant F | CNA | Named in dignity deficiency related to incontinence care |
| Certified Nursing Assistant M | CNA | Named in environmental deficiency related to wet blanket under AC unit |
| Business Office Manager | BOM | Named in environmental deficiency related to room rounds and AC unit |
| Maintenance Supervisor | Maintenance Supervisor | Named in environmental deficiency related to room maintenance |
| Maintenance Assistant | Maintenance Assistant | Named in environmental deficiency related to room maintenance |
| Activity Director | Activity Director | Named in activities deficiency related to resident #8 |
| Staff Development Coordinator | Staff Development Coordinator | Named in activities deficiency related to resident #8 |
| Licensed Practical Nurse L | LPN | Named in oxygen administration deficiency for resident #8 |
| B Wing Unit Manager | Unit Manager | Named in oxygen administration deficiency for resident #8 |
| Respiratory Therapist | RT | Named in oxygen administration deficiency for resident #8 |
| Licensed Practical Nurse B | LPN | Named in pain management deficiency for resident #637 |
| Licensed Practical Nurse D | LPN | Named in pain management deficiency for resident #637 |
| Registered Nurse C | RN | Named in pain management deficiency for resident #637 |
| Certified Nursing Assistant E | CNA | Named in dietary deficiency related to resident #636 and #128 |
| Certified Dietary Manager | CDM | Named in dietary and garbage storage deficiencies |
| Central Supply Staff | Central Supply | Named in oxygen concentrator filter cleaning deficiency |
| Director of Nursing | DON | Named in multiple deficiencies including MDS, oxygen, pain management, and QAPI |
| Administrator | Administrator | Named in QAPI deficiency |
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