Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Anchor Care & Rehabilitation Center during CMS and state inspections, most recent first.
Staff did not offer or ensure hand hygiene for residents before meals in both the main and small restorative dining rooms. Multiple staff members acknowledged that hand hygiene was not provided prior to meal service, despite understanding its importance in infection prevention. The facility's policy lacked clear guidance on when to offer hand hygiene to residents, resulting in inconsistent practices affecting numerous residents during meal times.
A resident with multiple chronic conditions was found self-administering her own eyedrops without a physician's order, assessment, or care plan documentation. Staff were aware of the practice, but no formal authorization or interdisciplinary assessment had been completed, contrary to facility policy requiring such measures before allowing self-administration of medications.
Two residents experienced significant delays in receiving care after using their call lights, with staff turning off the lights and either failing to communicate the residents' needs or declining to assist because the residents were not assigned to them. One resident waited over 45 minutes for incontinence care, while another had to leave her room to request pain medication after repeated unanswered calls. Facility policy required all staff to respond to call lights and ensure follow-through, but this was not consistently practiced, resulting in unmet resident needs.
The facility did not maintain the kitchen walk-in freezer in safe operating condition, resulting in ice buildup and water leakage onto stored food. The issue was reported by the Dietary Manager, but maintenance staff did not respond promptly, and there was confusion regarding communication and lack of a clear policy for equipment repair.
A resident with dementia eloped from the facility unsupervised by following a visitor out, due to staff failing to adhere to the visitor process. The resident was not identified as at risk for elopement, and staff did not confirm her identity or ensure she wore a visitor badge, leading to her unsupervised departure.
A resident with dementia eloped from the facility due to inadequate admission assessment and supervision. The resident, described as low maintenance by family, was not properly evaluated for elopement risk despite a history of wandering. She left the facility unsupervised, following a visitor out, and was missing for over an hour, highlighting a significant oversight in the facility's admission process.
Failure to Provide Hand Hygiene to Residents Before Meals
Penalty
Summary
The facility failed to implement an effective infection prevention and control program by not providing or offering hand hygiene to residents prior to meals in both the main and small restorative dining rooms. Observations over several days showed that staff prepared dining areas and served meals to groups of residents without ensuring that hand hygiene was performed. Staff members, including CNAs, acknowledged that they did not offer hand hygiene to residents before meals and confirmed that this practice was not routinely followed in the dining rooms. Some staff were aware of the importance of hand hygiene but did not implement it, and there was no system in place to verify if residents had cleaned their hands before eating. Interviews with staff, including the Infection Control Nurse and the Director of Nursing, revealed that while staff were trained on hand hygiene practices, there was no consistent process to ensure residents received hand hygiene before meals. The facility's hand hygiene policy specified that staff should wash their hands before and after eating but did not clarify when or how hand hygiene should be offered to residents. This lack of a clear system and consistent practice affected approximately 25 residents in the main dining room at lunch, 10 at dinner, and 10 in the small restorative dining room at lunch each day.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
A resident with diagnoses including chronic obstructive pulmonary disease, hypertension, anemia, major depressive disorder, anxiety disorder, and sepsis was found to be self-administering her own eyedrops without a physician's order, assessment, or care plan documentation supporting self-administration. The resident, who was cognitively intact, kept a bottle of Refresh eyedrops at her bedside and reported using them independently each morning and night since admission. Staff were aware of the resident's self-administration, but no formal assessment or authorization was present in the medical record. Upon review, it was confirmed by nursing staff that there were no physician's orders for the eyedrops or for self-administration, nor was there any documentation of an assessment or care plan addressing this practice. Facility policy requires an interdisciplinary team assessment and a physician's order before a resident may self-administer medications, as well as proper documentation and storage arrangements. The lack of assessment and documentation led to the deficiency cited in the report.
Failure to Provide Timely Response to Call Lights and Resident Care Requests
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards, the person-centered care plan, and residents' choices for two residents reviewed for call bell response. One resident, admitted for multiple conditions including hypertension, depression, and a urinary tract infection, was identified as high risk for falls and required frequent assistance due to incontinence. Despite being able to communicate his needs, the resident reported that staff would turn off his call light and state they would notify someone to assist him, but he often waited up to an hour and a half for help. On one occasion, after lunch, the resident waited over 45 minutes for assistance to have his brief changed, despite repeated requests. Staff interviews revealed miscommunication and lack of follow-through, with CNAs not being informed of the resident's needs and some staff declining to assist, stating the resident was not assigned to them. Another resident, admitted for diabetes, urinary tract infection, hypertension, anemia, acute kidney failure, and muscle weakness, also experienced delays in care. This resident, who had good cognitive function and communication abilities, reported that staff would turn off her call light and say they would inform someone else of her request, resulting in wait times ranging from 20 minutes to 2.5 hours. On one occasion, after repeated unanswered requests for pain medication, the resident had to leave her room and go to the nurse's station to obtain the medication herself. The nurse on duty did not recall being informed of the request and attributed the oversight to a busy shift. Facility policy required all staff to answer call lights and ensure that residents' needs were met, even if the initial responder could not provide the requested service. However, staff interviews and resident reports indicated that this policy was not consistently followed, leading to significant delays in care and unmet resident needs. Staff sometimes failed to communicate requests to the appropriate personnel or declined to assist residents not assigned to them, contrary to facility expectations and policy.
Failure to Maintain Kitchen Freezer in Safe Operating Condition
Penalty
Summary
The facility failed to maintain the kitchen walk-in freezer in safe operating condition, as observed during a kitchen tour when significant ice buildup was found on the evaporator and water was dripping onto food boxes stored below. The Dietary Manager relocated affected food items and confirmed the need for maintenance intervention. However, the Director of Maintenance and Regional Manager of Maintenance were initially unaware of the issue, stating that kitchen staff had not informed them. Later, it was revealed through a review of facility communications that the Dietary Manager had reported the issue via the manager chat, but the Director of Maintenance did not check the freezer at that time and subsequently forgot about the request. Further investigation identified a crack in the freezer's condenser and a separation in the outside wall, which allowed hot air to enter and caused the water leakage. The Director of Maintenance later acknowledged being informed of the problem but did not act promptly. Additionally, the facility was unable to locate a policy regarding expectations for equipment repair, despite the Plant Operations Director's job description outlining responsibility for maintaining equipment and responding to work order requests.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect a resident from neglect by not ensuring a secure environment and implementing measures to prevent elopement. The resident, who had been directly admitted from home with diagnoses including dementia and anxiety, left the facility unsupervised. The resident was able to exit the facility by following a visitor out, without staff noticing her absence for over an hour. This lapse in supervision placed the resident at significant risk due to her cognitive deficits and the busy roadway she walked along. The incident occurred when the resident, who was not identified as at risk for elopement despite her medical history, left the facility by following a visitor. The facility's visitor process was not adhered to, as the resident was mistaken for a visitor and allowed to exit the building. The staff failed to confirm the resident's identity and did not ensure she was wearing a visitor badge, which contributed to the oversight. The facility's investigation revealed that the staff did not follow the established visitor process, which required visitors to sign in and out and wear badges. The failure to differentiate between visitors and residents led to the resident's unsupervised departure. The facility's cameras captured the resident leaving, but staff did not realize she was missing until much later, highlighting a significant gap in the facility's supervision and security measures.
Removal Plan
- Resident #1 was placed on one-on-one supervision and re-evaluated for elopement risk.
- Nurse evaluation of the resident was completed with no signs of injury or distress.
- Education was initiated related to elopement standards and guidelines, Abuse and Neglect, and visitor process to ensure residents are identified to prevent elopement. Post-tests were completed to validate competency.
- Facility employees were provided education by the Leadership Team. 152 total facility employees (Nursing, Dietary, Laundry, Housekeeping, Therapy, Administrative staff, Maintenance Department employees) received the above mentioned education.
- Newly hired staff to receive the above education during orientation and prior to working an assignment.
- Elopement Risk Binders were reviewed to ensure they contained photos and demographic information of residents evaluated to be at risk for elopement.
- An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was completed with the Medical Director, Administrator, Director of Nursing and additional IDT (Interdisciplinary Team) members related to Elopement. The Performance Improvement Plan was accepted by the committee. Root Cause Analysis completed.
- The Front lobby receptionist hours were extended.
- As part of the ongoing QAA (Quality Assessment and Assurance) process, an ad hoc QAPI was conducted that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on elopement. No additional recommendations were made.
- Additional QAPI meetings were held to review PIP (Performance Improvement Plan) progress related to the elopement. No concerns were identified during ongoing quality reviews.
- Ongoing Quality Reviews were completed by the DON/designee to review visitor process with staff weekly, then once every 2 weeks, then monthly to ensure staff were able to verbalize the visitor process. 100 reviews were completed with 100% compliance.
- Administrator/designee to review 10 residents in LOA (Leave of Absence) book weekly, then once every 2 weeks, then monthly to ensure LOA process is followed. Reviews were completed with 100% compliance.
Failure to Prevent Resident Elopement Due to Inadequate Admission Assessment
Penalty
Summary
The facility failed to ensure the admission process was thoroughly completed by accurately evaluating and providing needed supervision to prevent elopement for a resident at risk for elopement. The resident, who had a diagnosis of dementia and other cognitive deficits, left the facility unsupervised and walked along a busy roadway. The staff were unaware of the resident's whereabouts for approximately one hour and twenty minutes, placing her at risk of severe injury or abduction. The resident was directly admitted from home and was described by her family as low maintenance and independent in activities of daily living. However, the admission evaluation did not accurately assess the resident's risk for elopement, as it failed to consider her history of wandering and cognitive impairments. The resident's granddaughter later revealed that the resident had previously wandered away from home multiple times, indicating a significant oversight in the admission process. On the day of the incident, the resident was observed in her room by staff at various times, but she managed to leave the facility by following a visitor out. The facility's staff, including the LPN/Evening Supervisor, did not recognize the resident as a risk for elopement, and the resident was able to exit the facility without being stopped. This lack of adequate supervision and failure to identify the resident's elopement risk contributed to the incident.
Removal Plan
- Resident #1 was placed on one-on-one supervision and re-evaluated for elopement risk. Nurse evaluation of the resident was completed with no signs of injury or distress.
- Education was initiated related to elopement standards and guidelines, Abuse and Neglect. Post-tests were completed to validate competency.
- Licensed nurses were educated on elopement standards and guidelines to include how to accurately conduct an elopement risk evaluation and implementation of appropriate immediate interventions to prevent the risk for elopement.
- 100% of licensed nurses completed the education.
- Newly hired licensed nurses will receive education on elopement standards and guidelines to include how to accurately conduct an elopement risk evaluation and implementation of appropriate immediate interventions to prevent the risk for elopement during orientation and prior to working on an assignment.
- Current residents were re-evaluated for elopement risk to ensure assessments were current and accurate. No additional residents were newly identified at risk for elopement. Care plans for current residents at Risk for Elopement were reviewed to validate appropriate interventions were in place related to Elopement Risk.
- Elopement Risk Binders were reviewed to ensure they contained photos and demographic information of residents evaluated to be at risk for elopement.
- The facility created and implemented a Community Admission Worksheet to include review for behaviors and history of wandering/elopement risk. Visual meet and greet to occur with prospective admissions from the community. The Administrator educated admission team on the new process.
- Elopement drills were conducted on every shift. Drills continued weekly.
- An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting was completed with the Medical Director, Administrator, Director of Nursing and additional IDT (Interdisciplinary Team) members related to Elopement. The Performance Improvement Plan (PIP) was accepted by the committee. Root Cause Analysis (RCA) completed.
- An ad hoc QAPI was conducted that included the Medical Director, Administrator, Director of Nursing and additional IDT members to review the plan viability on elopement. No additional recommendations were made at that time.
- An additional review was completed by the IDT on current residents at risk for elopement. Hourly safety checks were initiated for residents at risk for elopement. Care plans were reviewed/updated.
- Additional QAPI meetings were held to review the PIP progress related to the elopement. No concerns were identified during the ongoing quality reviews.
- Ongoing Quality Reviews: DON/designee to review new admissions/re-admissions and residents with significant change in condition for Elopement Risk Status to ensure elopement risk evaluation is current and accurate for residents identified at risk, the resident's care plan reflects the risk with appropriate/person-centered interventions. Reviews were completed with 100% compliance.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 60 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Palm Bay
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aviata At Palm Bay | 1 mi | ★★★★★ | 1 | 0 |
| Life Care Center Of Palm Bay | 1.5 mi | ★★★★★ | 0 | 0 |
| Atlantic Shores Nursing And Rehab Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Melbourne Terrace Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Avante At Melbourne Inc | 4.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Anchor Care & Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.