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 Melbourne Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to adhere to professional standards for food storage and sanitation, as observed during a kitchen tour. Improperly labeled and dated food items were found in the walk-in refrigerator and freezer, including leftover meats and vegetables, undated eggs, and cheese. Additionally, issues were noted in the dry storage room and with the cleanliness of the kitchen floor. The facility's policies on food storage and labeling were not followed, potentially affecting all residents consuming food prepared in the kitchen.
The facility failed to honor residents' dignity by using inappropriate labels and did not adequately support a resident's healthcare coordination needs. Staff referred to residents needing assistance with eating as 'feeders,' and a resident's Medicaid recertification was mishandled, delaying medical care and relocation plans.
The facility failed to provide a homelike environment and maintain cleanliness in the dining room and resident rooms. The dining room lacked tablecloths, centerpieces, and music, while resident rooms had issues with sticky floors, dirty air conditioning filters, and unpleasant odors. The Environmental Director acknowledged these issues and the need for better oversight of cleaning practices.
The facility did not post the required daily nursing staffing information, omitting the number and type of staff and the facility name on the Nurse Staffing Form. The Staffing Coordinator and Administrator cited company changes and uncertainty about the facility name as reasons for these omissions.
The facility failed to ensure residents performed hand hygiene before meals, as observed on multiple occasions where residents were not offered means to clean their hands before eating. Staff acknowledged the oversight, and the facility's policy emphasized the importance of hand hygiene, which was not consistently practiced.
The facility failed to conduct a medication self-administration assessment for two residents, leading to a deficiency in ensuring the safety of self-administered medications. One resident was observed with an inhaler at her bedside without a physician's order for self-administration, while another had an inhaler in her pocket with no documented assessment for self-administration. The DON confirmed that the facility's policy requires an assessment and a care plan for self-administration, which were not followed.
The facility failed to ensure accurate PASARR evaluations for two residents, leading to deficiencies in their mental health assessments. One resident's PASARR was missing diagnoses of major depressive disorder, panic disorder, and PTSD, while another's lacked the diagnosis of psychotic disorder with delusions. The Lead MDS Coordinator acknowledged these oversights, and the facility initiated a Performance Improvement Project to address the issues, but confusion remained about the accuracy of diagnoses listed in PASARR forms.
A facility failed to document a resident's blood pressure before administering Midodrine HCL, as required by the care plan. The resident, with conditions including Parkinsonism and syncope, had specific parameters for medication administration based on blood pressure readings. However, the facility did not consistently record these readings, leading to medication being given without confirming if the systolic blood pressure was within the prescribed limits.
The facility failed to provide respiratory care according to professional standards and physician orders for two residents. One resident received oxygen at a higher rate than prescribed without documented approval, while another received oxygen without a physician's order and had outdated tubing. These lapses were acknowledged by the facility's staff, indicating non-compliance with established policies.
A facility failed to ensure pharmacist recommendations were addressed by a physician for a resident at risk for falls due to psychotropic medications. The pharmacist suggested evaluating and possibly tapering Mirtazapine and Gabapentin after a fall, but these were not addressed. The DON confirmed the oversight, which was not in line with facility policy requiring physician documentation of actions taken on pharmacist recommendations.
A resident fell from her bed due to improper technique used by a CNA during incontinence care, resulting in a laceration. The facility failed to report the incident as neglect to the State Survey Agency within the required timeframe, delaying the report by 42 hours. The delay was due to the facility's practice of discussing incidents in IDT meetings held on Mondays, which postponed the recognition of the incident as reportable.
A resident with cognitive and mobility impairments eloped from a facility unsupervised, traveling 0.7 miles before being found by his son. Despite a care plan addressing elopement risk, staff failed to notice his absence for 90 minutes, and the facility's elopement protocol was not promptly activated. Interviews revealed inadequate communication and training among staff regarding residents at risk for elopement.
A resident with cognitive and mobility impairments eloped from a facility due to inadequate supervision and security measures. The resident exited through an unlocked door and wandered unsupervised for approximately two hours before being located. Staff were unaware of the resident's absence and did not follow elopement protocols promptly, failing to contact local authorities for assistance. The facility's lack of secure environment and staff training contributed to the incident.
A resident with physical and cognitive impairments exited the facility unsupervised due to ineffective elopement prevention measures. The facility's lobby doors and alerting systems were not activated, and staff were unaware of the resident's absence for about two hours. The Maintenance Director and DON were aware of the issues, but necessary revisions and implementations were delayed, leading to the resident's elopement.
Improper Food Storage and Sanitation Practices
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed during a kitchen tour. Several food items in the walk-in refrigerator were improperly labeled and dated, including leftover mechanical soft pork, sweet potatoes, corn, and mashed potatoes, which were kept beyond the facility's stated policy of three days for meat and five days for vegetables. Additionally, there were undated and open packages of hard-boiled eggs, whole eggs, tilapia fish, and fried eggs, which were discarded by the Assistant Dietary Manager. In the walk-in freezer, there were undated bags of leftover pork and Salisbury steak with frost buildup, and undated chicken tenders, all of which were also discarded. In the cook's reach-in refrigerator, there were undated stacks of American cheese slices and unlabeled tubs of leftover peaches and fruit cocktail, which were discarded as well. Further observations revealed issues in the dry storage room, where an unlabeled and undated bin contained a bag of sugar and an opened, undated bag of evaporated milk. A dirty tray held clean drinking glasses intended for resident use. Under the cook's food preparation table, three dry storage bins lined with dirty plastic bags contained flour with no indication of when it was received or opened, and a flying insect was observed near the dirty flour bin. Additionally, the kitchen floor tiles and grout had a buildup of a black substance, particularly around the floor drains. The facility's policies on food storage and labeling were not adhered to, as evidenced by the lack of proper labeling, dating, and sanitation practices, which could potentially affect all residents consuming food prepared in the kitchen.
Failure to Honor Resident Dignity and Support Healthcare Coordination
Penalty
Summary
The facility failed to honor residents' dignity by using inappropriate labels and did not adequately support a resident's healthcare coordination needs. During a lunch meal service, staff members referred to residents who required assistance with eating as 'feeders,' which was acknowledged by the Administrator as inappropriate and against the facility's policy on dignity. This labeling was observed and confirmed through staff interviews, indicating a lack of adherence to the facility's dignity policy. Additionally, the facility did not timely assist a resident with maintaining active health insurance, which affected his access to necessary medical care and his plans to move to an assisted living facility. The resident, who had intact cognition, had requested help with recertifying his Medicaid insurance in October 2024. However, the Business Office Manager failed to follow up on the recertification process, resulting in the resident losing his insurance coverage. This oversight delayed his dermatology appointments and his transfer to an assisted living facility, as his Medicaid status was crucial for these processes. The resident's medical records indicated a need for dermatology and ophthalmology referrals, which were delayed due to the insurance issue. The Business Office Manager's failure to ensure the Medicaid recertification was processed in a timely manner, along with the Social Services Director's awareness of the resident's desire to move, contributed to the resident's prolonged wait for appropriate care and relocation. The facility's policy on exercising resident rights emphasizes maintaining self-esteem and self-worth, which was not upheld in this case.
Failure to Maintain Homelike Environment and Cleanliness
Penalty
Summary
The facility failed to provide a homelike environment in the dining room and resident rooms, as observed during a survey. In the dining room, 36 residents were observed eating lunch without tablecloths, centerpieces, or music to create a homelike atmosphere. The Director of Activities acknowledged the absence of these elements and was unsure why they were not being used, despite the facility having seasonal centerpieces available. In the resident rooms, cleanliness issues were noted. Resident #13's room had dirty shoe marks, sticky floors, and a large patched area on the wall that was not repainted. Housekeeping staff used one mop head per room and did not change mop water throughout their shift, contributing to the stickiness. The Environmental Director expected fresh cleaning water to be used twice daily but acknowledged missed areas during deep cleaning. Resident #20's room had sticky floors, a brown hue on the toilet seat, and a sewer-like odor in the bathroom. The Environmental Director confirmed these issues and noted the need for better oversight of cleaning practices. Resident #62's room had gray and black debris on the floor, scratched and peeling paint, and a dirty air conditioning filter. The Environmental Director confirmed these observations and acknowledged the need for more thorough cleaning. The facility's policy stated that residents have the right to a safe, clean, comfortable, and homelike environment, but the observations indicated a failure to meet these standards.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nursing staffing hours, which should identify the number and type of nursing staff working in the facility. Observations on multiple dates revealed that the Nurse Staffing Form, located by the receptionist in the lobby, did not include this information. The Staffing Coordinator, responsible for posting the form, acknowledged that the facility name was missing and the form did not specify the number and type of staff. The Coordinator attributed this to ongoing company changes, leading to uncertainty about which company name to use. The Administrator confirmed that the facility had stopped including the facility name on the posted daily staffing sheet after receiving a call about a name change, despite the requirement for public viewing.
Failure to Ensure Hand Hygiene Before Meals
Penalty
Summary
The facility failed to establish a system for the prevention of communicable diseases by not ensuring that all residents were offered and encouraged to perform hand hygiene before meals in the dining room. On multiple occasions, residents were observed eating meals without being offered a means to clean their hands. Specifically, on March 4th, approximately 28 residents were observed eating lunch without being offered hand hygiene options, with some residents stating they were only offered a napkin. Similarly, on March 5th, residents who participated in morning exercises and snacks were not provided with hand hygiene options before lunch. Recreation Aide H and the Activities Director acknowledged the oversight, with the aide stating that residents were expected to use a sink in the dining room or be taken back to their rooms if their hands were very dirty. The Activities Director admitted that it had not occurred to her to ensure hand hygiene right before meals and planned to discuss this with the Administrator. The facility's policy on hand hygiene emphasized the importance of cleaning residents' hands and faces before and after meals, with wet wipes to be available at all times, highlighting a discrepancy between policy and practice.
Failure to Conduct Medication Self-Administration Assessment
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for two residents, leading to a deficiency in ensuring the safety of self-administered medications. Resident #44, who was cognitively intact with a BIMS score of 15/15, was observed with an Albuterol Tartrate HFA inhaler on her overbed table, which she stated she used as needed. However, there was no physician order allowing her to keep the inhaler at her bedside or to self-administer the medication. Similarly, Resident #92, also cognitively intact with a BIMS score of 15/15, was found with an inhaler in her jacket pocket. Although there was a physician order for her to keep the inhaler at the bedside, there was no documented assessment for her ability to self-administer the medication. The Director of Nursing (DON) confirmed that the facility's policy requires an assessment for self-administration to be performed by nursing staff, a physician's order for self-administration, and a care plan for self-administration of drugs to be initiated. The DON acknowledged that these procedures were not followed for both residents. The facility's policy, dated 2/21/23, states that residents may self-administer medications only if the attending physician and the Interdisciplinary Care Planning Team determine they have the decision-making capacity to do so. The failure to adhere to these policies resulted in the deficiency noted in the report.
Deficiencies in PASARR Evaluations for Residents
Penalty
Summary
The facility failed to ensure accurate Preadmission Screening and Resident Review (PASARR) evaluations for two residents, leading to deficiencies in their mental health assessments. Resident #55 was admitted with multiple psychiatric diagnoses, including major depressive disorder, panic disorder, and PTSD, which were not updated in her PASARR Level I screen. The Lead MDS Coordinator acknowledged the oversight, noting that the PASARR was missing these critical diagnoses, which were only partially listed as anxiety disorder. Similarly, Resident #26's PASARR forms were incomplete, lacking the diagnosis of psychotic disorder with delusions, despite her care plan indicating impaired cognition due to psychosis and dementia. The Lead MDS Coordinator admitted to missing this diagnosis in the PASARR update. The facility had initiated a Performance Improvement Project to address these issues, but there was confusion among staff about the accuracy and completeness of the diagnoses listed in the PASARR forms. The Social Service Director was unable to confirm whether the diagnoses listed in an email were current or needed to be added to the PASARR, indicating a lack of clarity in the facility's auditing process.
Failure to Document Blood Pressure Before Medication Administration
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. The resident, who was admitted with diagnoses including Parkinsonism, anemia, syncope, and hypertensive heart disease, had a care plan that required regular monitoring of blood pressure and administration of Midodrine HCL with specific parameters. However, the facility did not consistently document the resident's blood pressure readings, which were crucial for determining whether the medication should be administered. The deficiency was identified when it was found that the resident's blood pressure was not documented on several occasions, and the medication was administered without confirming if the systolic blood pressure was within the prescribed parameters. The assigned nurse and the South Wing Unit Manager acknowledged the lack of documentation and the potential oversight in administering the medication. The Director of Nursing confirmed that the blood pressure was not recorded, and the medication was given, highlighting a lapse in following the facility's policy for administering medications safely and as prescribed.
Failure to Follow Respiratory Care Orders
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards and physician orders for two residents. Resident #35, who had a history of COPD, pulmonary embolism, and other conditions, was observed receiving oxygen at 3 liters per minute (LPM) instead of the prescribed 2 LPM. Despite the resident's claim that a pulmonologist approved the higher oxygen level, there was no documented order to support this change. The Licensed Practical Nurse (LPN) and Unit Manager confirmed the discrepancy, acknowledging that the oxygen orders were not followed. Resident #85, admitted with conditions including type II diabetes, heart failure, and chronic kidney disease, was receiving oxygen without a physician's order. The resident reported using oxygen daily, including during dialysis, and noted that the oxygen tubing was not changed as scheduled. The LPN confirmed the absence of an order for oxygen and that the tubing had not been changed in nine days. The facility's admission form incorrectly indicated no respiratory risk, despite the resident's need for oxygen and a history of congestive heart failure. The facility's policies on oxygen administration and physician orders were not adhered to, as evidenced by the lack of verification of physician orders and failure to change oxygen tubing as required. The Director of Nursing and the Administrator acknowledged these lapses, which were contrary to the facility's established procedures for ensuring safe and appropriate respiratory care.
Failure to Address Pharmacist Recommendations for Resident Medications
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were addressed by the physician for a resident reviewed for unnecessary medications. The resident, who was admitted with multiple diagnoses including nontraumatic intracerebral brain hemorrhage, muscle weakness, and anxiety, was at risk for falls due to weakness and adverse effects of psychotropic medications. The pharmacist had submitted recommendations for the physician to evaluate and potentially adjust the resident's medication regimen, specifically suggesting a tapering of Mirtazapine and Gabapentin due to a recent fall. However, these recommendations were not addressed by the physician. The Director of Nursing (DON) confirmed that the pharmacist's drug regimen reviews and recommendations had not been addressed prior to her tenure and had not yet been addressed by her. The facility's policy required that any irregularities reported by the pharmacist be documented by the attending physician, indicating what actions were taken or the rationale for not making changes. The Administrator expected the DON to notify the physician and document their response in a timely manner, but was unaware that some recommendations from January had not been addressed. This oversight led to a deficiency in the facility's compliance with its own policies and procedures regarding pharmacist recommendations.
Delayed Reporting of Neglect Incident
Penalty
Summary
The facility failed to report an allegation of neglect to the relevant State Agencies within the regulatory timeframe. A resident, who was bedbound and required total assistance with activities of daily living, fell from her bed while a CNA was providing incontinence care. The CNA used improper technique by turning the resident away from her, resulting in the resident rolling off the bed and sustaining a laceration to her right temple. This incident was classified as possible neglect by the facility's Interdisciplinary Team (IDT) during a meeting held three days after the incident. The Director of Nursing (DON) was informed of the incident shortly after it occurred, but the facility did not submit an Immediate Report to the State Survey Agency until 42 hours after the allegation was made. The facility's policy requires that such allegations be reported immediately, or within 24 hours if no serious bodily injury occurred. The delay in reporting was attributed to the facility's practice of discussing incidents in IDT meetings held on Mondays, which in this case, delayed the recognition of the incident as reportable. The resident's family was notified of the fall and subsequently filed a grievance alleging negligence, which was not acknowledged by the facility until two days later. The grievance, along with the reenactment of the incident by the CNA, led the facility to decide that the incident was reportable. Despite the facility's policy and the availability of the reporting system over the weekend, the DON focused on the CNA's adherence to the resident's care plan rather than the immediate reporting requirements.
Neglect in Preventing Resident Elopement
Penalty
Summary
The facility failed to protect a resident from neglect by not implementing measures to prevent elopement. A cognitively and physically impaired resident, who was at risk for elopement, exited the facility unsupervised. The resident wandered through a parking lot, crossed a road, and traveled approximately 0.7 miles along a busy road. The facility was unaware of the resident's absence until a Registered Nurse noticed he was missing, and a search was not initiated for approximately 90 minutes. The resident was eventually found in a shopping center parking lot by his son, who informed the facility of his location. The resident had a history of dementia, diabetes, and mobility issues, requiring assistance with activities of daily living and ambulation. His care plan included interventions for potential elopement, such as monitoring for exit-seeking behavior and the use of a wanderguard. Despite these measures, the resident was able to leave the facility without staff noticing. Interviews with staff revealed that the resident frequently expressed a desire to leave and had a history of wandering, yet these behaviors were not adequately addressed or communicated among the staff. Staff interviews indicated a lack of urgency and communication in responding to the resident's elopement. The Director of Nursing was not informed promptly, and the facility's elopement protocol was not activated in a timely manner. Additionally, some staff members were unaware of the resident's appearance or the procedures for locating a missing resident, highlighting deficiencies in staff training and communication regarding residents at risk for elopement.
Removal Plan
- The resident was returned to the facility and immediately received a nursing physical assessment with no findings of injuries or identified concerns. The physician and resident representative were notified of the event.
- The Elopement Risk Alert Binder was reviewed to ensure all residents at risk for elopement had a picture and demographics in place. The affected resident remained on 1:1 supervision.
- The facility conducted a head count of all current residents; all were safe and accounted for.
- All exit doors were assessed by the Executive Director and Maintenance Director to ensure proper functioning; no issues or concerns were identified.
- Re-evaluations/review of all current residents for elopement risk was conducted.
- All door codes were changed.
- An Immediate Federal Report was filed.
- DCF (Florida Department of Children and Families) agent arrived to investigate inadequate supervision with findings unsubstantiated.
- The DON/designee reviewed elopement binders to ensure residents at risk for elopement were present and identified.
- The Executive Director/designee and DON/designee began reviews to ensure the safety and well-being related to elopement was maintained by the continued participation, evaluation, and intervention through maintaining the Quality Assurance/Performance Improvement (QAPI) process.
- Weekly audits were initiated on the components of elopement care management system with emphasis on adequate supervision. Audit findings were reported to the QAPI Committee weekly until a committee determination of substantial compliance and recommendation of monthly monitoring by the Regional Director of Clinical Operations when completing their systems review.
- French door magnetic lock system was reactivated by maintenance. The front door screamer system was assessed and found to be working properly; the volume was increased.
- Review of all residents identified at risk for elopement was completed by Unit Manager/designee for Elopement Screen, Care Plans related to wandering risk, CNAs Kardex reflective of resident status, and presence in Elopement Binders.
- The Maintenance Director contacted local electrical vendor for door alarm and nurse call system inspections; inspections were completed with no identified concerns.
- The DON/designee educated staff on: components of regulation F600 with an emphasis on abuse, neglect, and adequate supervision with posttests.
- 100% of actively working staff were re-educated in person and/or via telephone; no inactive or scheduled staff were permitted to work without prior receipt of in-person education. Any future newly hired employees were to receive the same education with orientation.
- Electrician provider was contacted for addition of wanderguard (alerting bracelet) system installation.
- 24-hour door monitors were scheduled until the wanderguard system installation completion.
- Ad Hoc QAPI attended by Medical Director, DON, and Regional President (in place of Nursing Home Administrator), and Regional Nurse Consultant was convened to review the components of ongoing elopement, the Charter Performance Improvement Plan (PIP) that included education, drills, resident evaluations, door and alarm checks, elopement risk binders placement and accuracy, french door at lobby exit magnetic lock functioning, 24-hour door monitors, new wanderguard system in place and audits completed, and systemic change and effectiveness review.
- Plans and interventions in place were determined by the facility to be effective.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to provide adequate supervision and a secure environment to prevent the elopement of a resident who was physically and cognitively impaired. The resident, who had a history of dementia, diabetes, and mobility issues, was able to exit the facility unsupervised when an unknown staff member unlocked the door. The resident wandered through the parking lot, crossed a two-lane road, and traveled approximately 0.7 miles along a four-lane road with moderate traffic, placing him at risk for serious injury or death. The resident's medical records indicated he was at risk for elopement due to cognitive impairment, decreased mobility, and poor decision-making skills. Despite these risks, the facility did not implement adequate interventions to prevent his elopement. Staff were unaware of the resident's whereabouts for approximately two hours until his son called to inform them of his location. Interviews with staff revealed a lack of awareness and urgency in responding to the resident's absence, and the facility's elopement protocols were not followed promptly. The facility's failure to maintain a secure environment and provide adequate supervision was compounded by issues such as unlocked doors, lack of staff training on elopement procedures, and insufficient communication among staff regarding high-risk residents. The resident's elopement was not promptly addressed, and the facility did not contact local authorities to assist in the search, further delaying the resident's safe return.
Removal Plan
- The resident was returned to the facility and immediately received a nursing physical assessment with no findings of injuries or identified concerns. The physician and resident representative were notified of the event.
- The Elopement Risk Alert Binder was reviewed to ensure all residents at risk for elopement had a picture and demographics in place. The affected resident remained on 1:1 supervision.
- The facility conducted a head count of all current residents; all were safe and accounted for.
- All exit doors were assessed by the Executive Director and Maintenance Director to ensure proper functioning; no issues or concerns were identified.
- Re-evaluations/review of all current residents for elopement risk was conducted.
- All door codes were changed.
- An Immediate Federal Report was filed.
- DCF agent arrived to investigate inadequate supervision with findings unsubstantiated.
- The DON/designee reviewed elopement binders to ensure residents at risk for elopement were present and identified.
- The Executive Director/designee and DON/designee began reviews to ensure the safety and well-being related to elopement was maintained by the continued participation, evaluation, and intervention through maintaining the Quality Assurance/Performance Improvement (QAPI) process.
- Weekly audits were initiated on the components of elopement care management system with emphasis on adequate supervision. Audit findings were reported to the QAPI Committee weekly until a committee determination of substantial compliance and recommendation of monthly monitoring by the Regional Director of Clinical Operations when completing their systems review.
- French door magnetic lock system was reactivated by maintenance. The front door screamer system was assessed and found to be working properly; the volume was increased.
- Review of all residents identified at risk for elopement was completed by Unit Manager/designee for Elopement Screen, Care Plans related to wandering risk, CNAs Kardex reflective of resident status, and presence in Elopement Binders.
- The Maintenance Director contacted local electrical vendor for door alarm and nurse call system inspections; inspections were completed with no identified concerns.
- The DON/designee educated staff on: components of regulation F600 with an emphasis on abuse, neglect, and adequate supervision with posttests.
- 100% of actively working staff were re-educated in person and/or via telephone; no inactive or scheduled staff were permitted to work without prior receipt of in-person education. Any future newly hired employees were to receive the same education with orientation.
- Electrician provider was contacted for addition of wanderguard (alerting bracelet) system installation.
- 24-hour door monitors were scheduled until the wanderguard system installation completion.
- Ad Hoc QAPI attended by Medical Director, DON, and Regional President (in place of Nursing Home Administrator), and Regional Nurse Consultant was convened to review the components of ongoing elopement, the Charter Performance Improvement Plan (PIP) that included education, drills, resident evaluations, door and alarm checks, elopement risk binders placement and accuracy, french door at lobby exit magnetic lock functioning, 24-hour door monitors, new wanderguard system in place and audits completed, and systemic change and effectiveness review.
- Plans and interventions in place were determined by the facility to be effective.
Failure in Elopement Prevention Measures
Penalty
Summary
The facility's administration failed to implement effective elopement prevention measures, resulting in a physically and cognitively impaired resident exiting the facility unsupervised. On the evening of 10/26/24, the resident left through the front entrance after an unknown staff member unlocked the door. The resident wandered through the parking lot, crossed a two-lane road, and traveled approximately 0.7 miles along a four-lane road with moderate traffic. The facility was unaware of the resident's elopement until a Registered Nurse noticed the resident was missing, but a search was not initiated for approximately 90 minutes. The resident was eventually located in a shopping center parking lot after being missing for about two hours, with the facility only learning of his location when the resident's son called. The investigation revealed that the facility's lobby doors and alerting bracelet alarm systems were not activated, despite the former Nursing Home Administrator being aware of these issues since March 2024. The Maintenance Director confirmed that the magnetic lock system was not functioning properly and that the double door alarm was not utilized by staff. Partial inspections were conducted, but necessary revisions were not completed until after the elopement incident. The Director of Nursing expressed concerns about the lack of an alerting bracelet system and noted that the equipment box at the front exit was not activated. Despite being aware of the high cost, the system was not implemented, and the issue remained unresolved for several months.
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 Melbourne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Melbourne | 0.2 mi | ★★★★★ | 2 | 0 |
| Avante At Melbourne Inc | 0.5 mi | ★★★★★ | 0 | 0 |
| Melbourne Terrace Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| West Melbourne Health & Rehabilitation Center | 2.6 mi | ★★★★★ | 14 | 0 |
| Atlantic Shores Nursing And Rehab Center | 2.9 mi | ★★★★★ | 0 | 0 |
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