Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Indian River Center during CMS and state inspections, most recent first.
A facility failed to prevent abuse and neglect when a resident with severe cognitive impairment was attacked by another resident with a history of aggressive behavior. The injured resident suffered a fractured jaw and did not receive timely medical care, leading to his death. The staff failed to monitor the aggressive resident adequately and did not document or report the incident promptly, contributing to an unsafe environment for all residents in the memory care unit.
A facility failed to thoroughly investigate an alleged resident-to-resident abuse incident involving a cognitively impaired resident, leading to unaddressed injuries and eventual death. Despite a CNA's report of suspicious behavior, the nurse on duty did not act, and the facility concluded the allegations were unverified. The resident suffered jaw fractures, and the facility's inadequate documentation and delayed reporting placed residents at risk, resulting in Immediate Jeopardy.
The facility failed to ensure resident safety and timely medical care, resulting in a resident suffering a bilateral jaw fracture after an altercation with another resident. The administration's lack of involvement and deficient monitoring and reporting standards contributed to the incident. The facility did not provide necessary mental health services or a comprehensive care plan for a resident with aggressive behaviors, leading to an unsafe environment in the memory care unit.
The facility failed to complete PASARR Level II Evaluations for two residents with serious mental illnesses and did not conduct a Level I screen after a significant change in condition for one resident. One resident, admitted from a psychiatric hospital, exhibited aggressive behaviors, yet the facility was unaware of his Level II evaluation results. Another resident, admitted from Hospice, required a Level II Evaluation, but the facility did not provide necessary records, leading to an administrative closure. The facility lacked a specific PASARR policy, relying instead on regulatory guidelines.
A resident with a PICC line did not receive proper dressing changes as per physician orders and facility protocol. The dressing, dated from the hospital, was not changed within 24 hours of admission or weekly thereafter, as required. The oversight was confirmed by the assigned RN, LPN, and DON, highlighting a lapse in following established PICC care procedures.
The facility failed to ensure accurate and complete PASARR documentation for several residents, leading to deficiencies in mental health assessments and referrals. Residents with psychiatric diagnoses such as major depressive disorder, bipolar disorder, and schizophrenia had incomplete or outdated PASARR forms. Staff, including the DON, acknowledged the lack of a formal policy or guidelines for updating these forms, resulting in missed updates and incomplete documentation.
The facility failed to implement its QAPI policies effectively, particularly in monitoring PASARR compliance. A PIP was initiated for PASARR concerns, but audits were inadequately documented and incomplete. A resident admitted during the Administrator's absence lacked a PASARR, and subsequent audits did not address this or other residents' PASARR issues.
The facility failed to maintain resident dignity during dining assistance by using inappropriate labels and improper feeding practices. CNAs referred to residents as 'feeders' and stood over them while assisting with meals, compromising their dignity. The Unit Manager intervened, advising staff to sit while assisting residents and avoid using labels. The facility's policies emphasized treating residents with respect and dignity.
A facility failed to obtain a Level I PASARR for a resident admitted with diagnoses including Parkinsonism, dementia, bipolar disorder, and depression. The resident's medical record lacked the required PASARR documentation, despite the use of medications for mental health conditions. The care plan addressed the use of antidepressant and antipsychotic medications, mood issues, and cognitive impairment. The Nursing Home Administrator acknowledged the missing PASARR, and the President of Operations noted the absence of a facility policy for PASARR.
Failure to Prevent Resident-to-Resident Abuse and Neglect
Penalty
Summary
The facility failed to prevent physical abuse of a vulnerable resident by another resident in the memory care unit, leading to severe injuries and eventual death. A resident with severe cognitive impairment was found with a fractured jaw after another resident, known for aggressive behaviors, was seen leaving his room with the resident's sheets. The incident was not immediately reported or documented by the staff, and the injured resident did not receive timely medical care, contributing to his transfer to an acute care hospital where he later died. The injured resident, an elderly male with a history of dementia and other medical conditions, was admitted to the facility after a hospital stay. Despite his severe cognitive impairment and need for assistance with daily activities, he was left vulnerable to an attack by another resident. The staff failed to monitor and supervise the aggressive resident adequately, who had a history of wandering into other residents' rooms and causing disturbances. This lack of supervision and failure to act on observed behaviors led to the tragic incident. The facility's documentation and response to the incident were inadequate. The staff did not perform a thorough assessment or document the incident in the medical records of either resident involved. The injured resident's condition was not promptly addressed, and the facility delayed in ordering necessary medical evaluations. The lack of immediate action and proper documentation contributed to an unsafe environment, putting all residents in the memory care unit at risk.
Inadequate Investigation of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of resident-to-resident physical abuse involving a vulnerable, cognitively impaired resident. The incident involved a resident who was reportedly seen by a CNA exiting another resident's room with bed sheets, following a report from the roommate that the resident was on top of the victim. Despite the observation, the nurse on duty did not check on the residents or report the incident to a supervisor. The following day, discoloration was noted on the victim's face, and subsequent x-rays revealed fractures of the jaw. The facility concluded that the allegations were not verified due to the lack of mental anguish and the cognitive impairment of the alleged aggressor. The facility's investigation was inadequate, as it did not thoroughly document findings or ensure appropriate corrective actions. The failure to investigate the injury of unknown origin and the lack of immediate medical care for the jaw fractures contributed to the resident's transfer to a higher level of care, where he died six days later. The facility did not maintain accurate records or provide a timeline of events, and there was a delay in reporting the incident to the appropriate authorities. The facility's actions placed the resident and other cognitively impaired residents at risk for physical abuse and neglect. Interviews with staff and family members revealed inconsistencies in the facility's handling of the incident. The CNA who reported the incident felt that his concerns were dismissed, and the resident's wife expressed concerns about safety and staff attentiveness. The facility's corporate staff later acknowledged the need to reopen the investigation due to inconsistencies in statements and the lack of a thorough investigation into the injury of unknown origin. The deficiency resulted in Immediate Jeopardy, affecting the safety of 60 residents in the memory care unit.
Failure to Ensure Resident Safety and Timely Medical Care
Penalty
Summary
The facility failed to promote a culture of safety on the locked memory care unit, resulting in negative resident-to-resident interactions, including physical fights and life-altering injuries. The administration's lack of active involvement and deficient behavioral monitoring, reporting, and investigative standards contributed to these incidents. Specifically, two residents were involved in an altercation that led to one resident suffering a bilateral jaw fracture, which was suspicious for non-accidental trauma. The facility did not ensure timely medical care for the injured resident, who was later transferred to hospice care and passed away. The administration failed to prevent physical abuse and ensure timely medical care for a vulnerable, cognitively impaired resident. The facility did not accurately document incidents and allegations of abuse in the medical record. Additionally, the facility did not provide necessary mental health services, appropriate monitoring, or a comprehensive person-centered care plan with behavioral interventions for a resident with known aggressive behaviors. This lack of intervention and oversight contributed to an unsafe environment for all residents in the memory care unit. The facility's investigation into the incident was inadequate, with missing documentation and a lack of effort to determine the root cause of the resident's injuries. The administration and corporate staff did not prioritize the investigation or implement appropriate interventions to maintain resident safety. The facility's failure to address the aggressive behaviors of one resident and the lack of a Level II PASARR screening further exacerbated the situation, leading to the life-altering injury of another resident.
Removal Plan
- resident #1 no longer resides in the facility, discharged.
- resident #2 no longer resides in the facility, discharged.
- staff noticed discoloration to resident #1's jaw/neck and notified APRN per orders for anticoagulant monitoring. Upon examination APRN ordered a facial x-ray. Resident #1 transferred to hospital for evaluation related to lab results.
- 200 of 200 current staff across all departments were provided education on abuse, neglect, exploitation, misappropriation, mistreatment, and injury of unknown source.
- x-ray results received by facility. The Unit Manager notified the APRN and the facility Risk Manager of the x-ray results. An internal investigation was initiated, and a federal immediate report was submitted.
- the NHA and DON were re-educated by the Registered Nurse Consultant on the components of F835 with an emphasis on taking immediate action on ensuring person centered care and interventions are in place for residents with a history of dementia and behaviors for effectiveness, thoroughly investigating and reporting allegations in a timely manner and appropriate interventions for behavioral dementia residents and timely medical treatment.
- a quality review was conducted by the RNC/designee of 57 current residents who reside on the memory care unit to ensure appropriate interventions for behavioral dementia residents are in place and timely medical treatment is rendered. No like residents were identified.
Failure to Complete PASARR Evaluations for Residents
Penalty
Summary
The facility failed to ensure a Pre-Admission Screening and Resident Review (PASARR) Level II Evaluation was completed for two residents and did not complete a Level I screen after a significant change in condition for one resident. Resident #2, a male with multiple psychiatric and cognitive diagnoses, was admitted from an in-patient psychiatric hospital. Despite his complex medical history and behaviors such as wandering and aggression, the facility was unaware of his Level II evaluation results until they obtained them from the psychiatric facility. The Director of Nursing acknowledged that discussions about the need for new PASARR evaluations occurred, but a new screen was not completed after the resident exhibited assaultive behaviors. Resident #4, a male admitted from Hospice with severe cognitive impairment and multiple psychiatric diagnoses, also did not have a completed Level II evaluation. Although a new PASARR screen indicated the need for a Level II Evaluation, the facility failed to provide the necessary medical records, leading to the administrative closure of the case. The Director of Nursing was unaware of the requirement for additional records and admitted that follow-up measures were missed to ensure the evaluation was completed. The facility lacked a company policy for PASARR and relied on regulatory guidelines, which contributed to the oversight in completing the necessary evaluations. The Regional Director of Operations confirmed the absence of a specific policy, highlighting a gap in the facility's procedures for managing residents with serious mental illnesses or intellectual disabilities.
Failure to Change PICC Line Dressing as Ordered
Penalty
Summary
The facility failed to ensure proper care and maintenance of a Peripherally Inserted Central Catheter (PICC) line for a resident, leading to a deficiency in the administration of intravenous (IV) fluids. The resident, a male with diagnoses including acute cystitis with hematuria, urinary tract infection, and chronic systolic heart failure, was admitted to the facility with a PICC line in place. According to the hospital discharge worksheet, the PICC line dressing was to be changed every 7 days or sooner if it became wet, soiled, or loose. However, upon observation, the dressing was found to be dated 1/24, indicating it had not been changed since the resident's admission on 1/29. The resident's assigned nurse, RN A, confirmed that the PICC line dressing should have been changed within 24 hours of admission and then every 7 days thereafter. Despite this, the dressing remained unchanged, and the date on the dressing was still 1/24. The facility's policy and the physician's orders both required routine PICC care, including dressing changes, which were not adhered to. The Medication Administration Record (MAR) indicated a dressing change on 1/30, but the date on the dressing did not reflect this change. Further investigation revealed that the Licensed Practical Nurse (LPN) B had signed off on the order for a dressing change without actually performing it, as she believed it was not needed at the time. The Director of Nursing (DON) and the East Coast RN Unit Manager both acknowledged the oversight and confirmed that the dressing should have been changed according to protocol. The facility's revised policy for Central Lines reiterated the requirement for routine dressing changes, which was not followed in this instance.
Deficiencies in PASARR Documentation and Mental Health Referrals
Penalty
Summary
The facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Review (PASARR) documents for several residents, leading to deficiencies in the assessment and referral process for mental health services. For instance, a resident admitted with multiple psychiatric diagnoses, including major depressive disorder and generalized anxiety disorder, had an incomplete PASARR form that did not reflect these conditions. The facility's staff, including the Social Services Director and the East Coast Unit Manager, acknowledged the oversight but indicated a lack of clarity regarding responsibility for updating PASARR forms. Another resident, admitted with diagnoses such as schizoaffective disorder and major depressive disorder, also had an incomplete PASARR form that failed to capture these mental health conditions. Despite regular psychiatric meetings involving social services and nursing staff, the facility did not update the PASARR forms to reflect new or existing psychiatric diagnoses. The Director of Nursing (DON) admitted to the absence of a policy governing the PASARR process, contributing to the oversight. Additional cases involved residents with conditions like bipolar disorder and paranoid schizophrenia, where PASARR forms were either outdated or incorrect, failing to list significant mental health diagnoses. The DON and other staff members expressed uncertainty about the PASARR process and acknowledged the lack of a formal policy or guidelines, resulting in missed updates and incomplete documentation. This systemic issue affected multiple residents, highlighting a significant gap in the facility's compliance with regulatory requirements for mental health assessments and referrals.
Deficiency in QAPI Implementation and PASARR Compliance
Penalty
Summary
The facility failed to effectively implement its Quality Assurance and Performance Improvement (QAPI) policies, particularly in monitoring and tracking performance in previously identified areas of concern. The QAPI committee, responsible for ensuring compliance with federal and state requirements, did not adequately oversee the implementation of Performance Improvement Projects (PIPs) as indicated by data analysis. A specific concern was identified related to Preadmission Screening and Resident Review (PASARR), and a PIP was initiated. However, the audit process for current residents to ensure each had a Level I PASARR completed was insufficiently documented, lacking dates and details of the audit process. The Nursing Home Administrator provided incomplete documentation for the audits of new admissions, which were supposed to be conducted weekly and then bi-weekly. A resident admitted during a week when the Administrator was absent did not have a PASARR in their medical record, and subsequent audits failed to include this resident. Additionally, five other residents were found during the survey to have unresolved PASARR concerns. The Administrator did not provide an explanation for the lack of follow-up on new admissions during off weeks or the unaddressed PASARR issues for these residents.
Failure to Maintain Resident Dignity During Dining Assistance
Penalty
Summary
The facility failed to treat residents with dignity and respect, as evidenced by the use of inappropriate labels and improper dining assistance practices. Certified Nursing Assistant (CNA) A was observed referring to residents as 'feeders' and standing over them while assisting with meals, which compromised their dignity. Specifically, CNA A was seen feeding a resident while standing and using the term 'feeders' to describe residents who required assistance with dining. The Unit Manager intervened, advising CNA A to sit while assisting residents to ensure comfort and maintain dignity. The Unit Manager acknowledged the importance of not using labels like 'feeders' and emphasized the need for staff to refer to residents requiring assistance as 'assisted diners.' Additionally, another incident involved CNA B, who left a meal tray at a resident's bedside for an extended period while the resident slept, and later referred to the resident as a 'feeder.' The Unit Manager expressed concern over the repeated use of the term and indicated a need for further staff education. The facility's policies on Activities of Daily Living (ADL) Care and Services and Residents Rights emphasized the importance of treating residents with respect and dignity, and training documents indicated that staff should avoid using labels and should be seated when assisting residents with meals.
Failure to Obtain PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to obtain a Level I Preadmission Screening and Resident Review (PASARR) for one of the residents reviewed, who was admitted with multiple diagnoses including Parkinsonism, dementia, bipolar disorder, depression, insomnia, and dysphagia. The resident's medical record did not contain a Level I or Level II PASARR, despite the presence of significant mental health diagnoses and the use of medications such as Quetiapine Fumarate, Donepezil, Mirtazapine, Lamotrigine, and Aripiprazole for conditions like bipolar disorder and dementia. The care plan for the resident included focuses on the use of antidepressant and antipsychotic medications, mood problems, and impaired cognitive function. The Nursing Home Administrator confirmed the absence of a Level I PASARR, and the President of Operations stated there was no facility policy or procedure for PASARR.
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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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near West Melbourne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| West Melbourne Health & Rehabilitation Center | 1.6 mi | ★★★★★ | 14 | 0 |
| Nursing & Rehabilitation Center Of Melbourne | 1.9 mi | ★★★★★ | 13 | 0 |
| Melbourne Healthcare And Rehabilitation Center | 3.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Melbourne | 3.8 mi | ★★★★★ | 2 | 0 |
| Avante At Melbourne Inc | 3.8 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.