Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atlantic Shores Nursing And Rehab Center during CMS and state inspections, most recent first.
Resident room walls on the South wing had multiple areas of damage, including holes, chipped paint, scraped surfaces, and patched areas that were not finished. Staff interviews showed the CNA and housekeeper did not consistently report the damage, and the Maintenance Director confirmed some repairs had been done previously while other damage remained unreported. The Administrator and DCS acknowledged the room conditions did not meet the facility’s expectations for a clean, comfortable environment.
Failure to Perform Proper Hand Hygiene During Meal Assistance: Staff in the South wing dining room were observed assisting residents with lunch while repeatedly failing to clean hands between residents and tasks. CNA F cut food, opened packages, handled trays, touched a resident’s wheelchair, and assisted multiple residents without consistent hand hygiene; when hand wipes were used, they were applied briefly and disposed of improperly. The UM and IP nurse stated staff were expected to wash with soap and water or use ABHR/hand wipes correctly and between residents.
Two residents with hearing deficits did not have comprehensive, person-centered care plans revised to reflect their hearing aid needs. One resident reported a lost hearing aid and difficulty hearing, yet the care plan still listed a hearing aid at bedside and there was no CNA Kardex entry or audiology consult. The other resident had documented hearing loss, prior audiology findings, and repeated reports of missing hearing aids, but the care plan did not address hearing aid care or missing devices. Staff gave inconsistent accounts of who was responsible for documenting and updating hearing aid information, and the facility had no hearing aid or assistive device policy.
A resident with PTSD, moderate cognitive impairment, depression, and dementia did not receive a trauma-informed care assessment or individualized care plan. Although a psych note documented a past physical altercation trauma and a dislike of aggressively yelling environments, the care plan and Kardex had no PTSD-specific instructions or trigger-avoidance guidance. The SS Director, LPN, Unit Manager, MDS Coordinator, CNA, and DON all acknowledged the gap, and the facility had no Trauma Informed Care policy.
Delayed review of a pharmacy consultant recommendation led to a resident continuing Eliquis after the physician had signed to discontinue it. The resident had multiple chronic conditions including DM, HTN, hyperlipidemia, prior PE, and dementia with psychotic disturbance, and was dependent for ADLs with impaired cognition and fall risk. Facility staff described a process of placing pharmacy recommendations in a binder, checking for signatures, and contacting the physician, but the MARs showed the anticoagulant remained active until it was finally discontinued.
Nurses failed to follow physician's orders and monitor a resident's condition changes timely, leading to emergency hospitalization. The resident, with complex medical conditions, had elevated blood pressure that was not adequately addressed or documented. A gap in monitoring and communication between shifts contributed to the deficiency.
A facility failed to conduct a medication self-administration assessment for a resident with severe cognitive impairment, leading to a deficiency. The resident had personal items, including Visine eye drops and B & C Ointment, on her nightstand without physician orders or evaluations. The resident's daughter confirmed she brought the eye drops and administered them during visits. The RN and DON acknowledged the lack of assessment and orders, which are required by facility policy.
Resident Room Wall Damage and Unreported Repairs
Penalty
Summary
The facility failed to maintain a clean and homelike environment in 6 of 12 resident rooms on the South wing. During repeated environmental observations, surveyors found multiple areas of wall damage in resident rooms, including holes in the wall above the baseboard, a hole under a window with drywall particles and a bent baseboard, walls that had been patched but were still not sanded or painted, and areas where paint had been scraped off or chipped away. One resident in bed B stated she did not recall how long the hole above the baseboard had been there and said she did not like seeing it on the wall. Staff interviews showed that damaged areas were not consistently reported or repaired. A CNA said she used a repair request sheet kept at the nurses’ station when repairs were needed, but she had not told her supervisor or anyone else about the new hole in the wall and the resident in bed B was unable to report the needed repairs herself. The assigned housekeeper said she had not seen the wall damage under the window, had not reported it, and had not filled out a repair requisition form. The Maintenance Director confirmed the damaged walls and stated that repair requisitions were supposed to be placed in the box at the nurses’ stations, that holes in walls were given priority, and that some areas had been previously repaired but were damaged again. The Administrator and Director of Clinical Services acknowledged that the observed room conditions did not meet the facility’s expectations for maintaining a clean, comfortable environment.
Failure to Perform Proper Hand Hygiene During Meal Assistance
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in the South wing dining room by not ensuring staff performed proper hand hygiene while assisting residents with lunch service. During observation, two CNAs and the Infection Prevention nurse were seen setting up meals, placing items from resident trays on tables, opening condiment packages, and cutting food for multiple residents. CNA F brought trays from the cart to residents, cut food, opened packages, and moved from one resident to another without washing or sanitizing hands between residents. Staff were also observed using hand wipes inconsistently and not following the product directions, including wiping hands briefly, not allowing hands to dry, and placing used wipes into a container on the beverage cart instead of disposing of them properly. On another observation, CNA F cut food for one resident, then moved to a neighboring resident and used that resident’s fork and knife to cut the food without performing hand hygiene between residents. CNA F also assisted several residents with opening butter and did not sanitize hands between each resident. Later, CNA F touched a resident’s wheelchair handlebars, handled dirty trays, and assisted another resident without performing hand hygiene between tasks. She was also observed washing her hands with water only, without soap, for less than four seconds on two occasions, and touching several residents’ backs while moving between tables without performing hand hygiene. The South Wing Unit Manager stated the expectation for CNAs assisting in the dining room was to assist one resident at a time and wash hands between residents. The Infection Prevention nurse stated staff were expected to wash with soap and water or use alcohol-based hand rub, and that hand wipes should be used to saturate all surfaces of the hands, then discarded in the garbage and allowed to air dry. The facility’s Infection Prevention and Control Plan stated the program was established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent communicable diseases and infections, and the Hand Washing/Hygiene Policy stated hand hygiene should be performed before and after assisting a resident with meals and for a minimum of 20 seconds.
Care Plans Not Updated for Hearing Aid Needs
Penalty
Summary
The facility failed to revise and review comprehensive person-centered care plans to address the hearing and sensory aid needs of two residents. For one resident, the record showed a hearing deficit on MDS assessments, but the care plan continued to state that a right-ear hearing aid was at bedside even though the resident reported that one hearing aid had been lost and the remaining hearing aid was not available. The resident stated she had difficulty hearing and needed others to speak close to her ear. The chart contained only one progress note mentioning hearing aids, and there was no documentation in the CNA Kardex for hearing aid use, assistance, or care. The EMR also did not show an audiology consult despite the hearing deficit and absence of hearing aids. For the second resident, the record showed a history of hearing loss, prior audiology evaluation, and documentation that staff were to assist with inserting and removing hearing aids daily and changing batteries weekly. The resident’s daughter reported that the hearing aids had been lost multiple times and that she had been told a plan would be developed to prevent future loss, but she had not been informed of any plan. The resident’s care plan addressed impaired communication and behavior, including that he sometimes declined his hearing aids, but it did not include a specific care plan for hearing aid care, assistance, or missing hearing aids. The CNA Kardex also did not include hearing aid documentation, and the medical record did not contain a personal effects or inventory form. Interviews with nursing, MDS, social services, and management staff showed inconsistent understanding of who was responsible for assessing, documenting, and updating hearing aid needs in the care plan. Staff described different processes for placing hearing aids in medication carts, documenting them on treatment records, or triggering CNA tasks, but they also acknowledged that there was no designated interdisciplinary team member responsible for updating care plans for hearing aids. The Regional Nurse Consultant stated the facility had no hearing aid policy or assistive device policy. The facility policy required comprehensive person-centered care plans with measurable objectives and timetables that were reviewed and revised after assessments and when resident needs changed, but the records for these two residents did not reflect that process for their hearing aid needs.
Missing Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to ensure a resident with PTSD received culturally competent, trauma-informed care that accounted for her experiences and preferences to help eliminate or reduce triggers that could cause re-traumatization. Resident #11 was admitted with diagnoses including a T11-T12 wedge compression fracture, type 2 diabetes mellitus, major depressive disorder, unspecified dementia, and PTSD. The MDS admission assessment showed a BIMS score of 8 out of 15, indicating moderately impaired cognition, and listed PTSD as an active psychiatric/mood disorder. A psychiatrist progress note documented that the resident reported a history of a physical altercation many years ago with one of her brothers, resulting in trauma to her right hand, and that she disliked aggressively yelling environments. However, the comprehensive care plan contained no specific plan addressing PTSD or her dislike of loudly aggressive environments, and the Kardex did not include special instructions for trauma-informed care. Records showed no trauma-informed assessment had been completed even though PTSD was listed on admission. The Social Services Director, LPN, Unit Manager, MDS Coordinator, CNA, and DON all acknowledged that the resident did not have a trauma-informed care plan and that one should have been completed; the facility also did not have a policy on Trauma Informed Care.
Delayed Review of Pharmacy Recommendation for Anticoagulant Discontinuation
Penalty
Summary
Ensure a licensed pharmacist performed a monthly drug regimen review, including the medical chart, and followed irregularity reporting guidelines in the facility’s policies and procedures. The facility failed to timely review pharmacy consultant recommendations and failed to implement a physician’s revised medication order for one resident reviewed for unnecessary medications. The resident was an older male admitted from an acute care hospital with diagnoses including type 2 diabetes mellitus, hypertension, hyperlipidemia, history of pulmonary embolism, and dementia with psychotic disturbance. His MDS indicated severely impaired cognitive decision-making, memory problems, dependence for ADLs, wheelchair use, and a prior fall with minor injury. His care plan included interventions for skin impairment, impaired cognition/communication, fall risk, impaired vision, leaning to the right in the wheelchair, and anticoagulant therapy monitoring. The pharmacy consultation report recommended discontinuing Eliquis because of long-term use, and the physician signed the form to discontinue the medication. However, the April, May, and June 2026 MARs showed the resident continued to receive Eliquis 5 mg twice daily until it was discontinued on 6/04/26. During interviews, the North Unit Manager said pharmacy recommendations were placed in a binder for physician review and that she checked daily for completion; the Medical Records Coordinator said she checked for signed pharmacy forms and contacted the physician when items were missing; and the DON said the facility had 30 days to act on recommendations and that she was not aware the Eliquis had not been discontinued until 6/04/26. The facility’s Medication Regimen Review standards stated it was responsible for timely alerting physicians of pharmacy recommendations and notifying the Medical Director of untimely responses.
Failure to Monitor and Document Resident's Condition
Penalty
Summary
Nurses at the facility failed to adhere to physician's orders and did not monitor a resident's condition changes in a timely manner. The resident, a male with multiple complex medical conditions including hemiplegia, aphasia, end-stage kidney disease, and coronary artery disease, was admitted to the facility and later re-hospitalized. His care plan required close monitoring for cardiovascular complications and side effects from hemodialysis. However, on one occasion, the resident's elevated blood pressure was not adequately addressed, and the necessary medication was not documented as administered. The incident involved a Licensed Practical Nurse (LPN) who received an order for Clonidine to manage the resident's high blood pressure but failed to document its administration. The resident's blood pressure was recorded as elevated, but there was a significant gap in monitoring, with no subsequent readings documented for approximately 12 hours. This lapse in monitoring and documentation led to the resident requiring emergency transport to the hospital from the dialysis center. Interviews with staff revealed that there was a lack of communication between shifts, and the Change of Condition evaluation was not completed as expected. The Director of Nursing acknowledged the failure to document the administration of medication and the lack of a policy for change in condition. The facility's assessment indicated that they provided care for residents with complex medical needs, yet the necessary protocols were not followed in this instance.
Failure to Conduct Medication Self-Administration Assessment
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for a resident, leading to a deficiency in ensuring the safety of self-administered medications. The resident, who was admitted with multiple diagnoses including severe cognitive impairment, was observed with personal items on her nightstand, including Visine eye drops and B & C Ointment, which were not prescribed or evaluated for self-administration. The resident's daughter confirmed she brought the eye drops to the facility and administered them during her visits, as her mother had used them at home. The assigned RN acknowledged the presence of the medications and confirmed there were no physician orders or self-administration evaluations for them. The Director of Nursing stated that the Interdisciplinary Team should conduct a self-administration assessment to ensure safety, and acknowledged that the resident would not be safe to self-administer medications due to her severe cognitive impairment. The facility's policy requires an IDT evaluation and physician order before a resident can self-administer medications, which was not followed in this case.
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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.
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Nursing homes near Melbourne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Melbourne Terrace Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Aviata At Palm Bay | 2.2 mi | ★★★★★ | 1 | 0 |
| Anchor Care & Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Avante At Melbourne Inc | 2.4 mi | ★★★★★ | 0 | 0 |
| West Melbourne Health & Rehabilitation Center | 2.8 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.