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 Rockledge Healthcare & Rehabilitation Center during CMS and state inspections, most recent first.
A resident was found with eye drops at their bedside without a physician's order or a completed self-administration assessment. The resident was cognitively intact, but the facility failed to follow its policy requiring an assessment and physician's order for self-administration of medications.
A facility failed to maintain a homelike environment in a resident's room due to a missing drawer in a nightstand. Despite a CNA entering work orders for the repair, the Maintenance Director was unaware of the issue, and the work orders did not reflect the needed repair. The Administrator expected staff to follow up on such issues, but the deficiency remained unresolved.
The facility failed to ensure accurate MDS assessments for two residents with serious mental illness (SMI) and one resident's insulin use. Two residents' MDS assessments incorrectly indicated they did not meet the state definition of SMI, despite PASARR reports confirming otherwise. Additionally, another resident's MDS assessment inaccurately documented insulin use, although no insulin was administered according to the MAR. The MDS Lead and coordinator confirmed these discrepancies.
The facility failed to ensure accurate completion of PASARR documents for several residents, leading to unlisted mental health diagnoses. A resident with major depressive disorder and another with multiple mental health conditions had PASARR forms that did not reflect their diagnoses. The MDS Coordinator and DON acknowledged the omissions, citing unclear responsibilities due to staff changes. The facility's policy requires screening for mental disorders before admission, but recent transitions led to inaccuracies in PASARR documentation.
A resident with respiratory and cardiac conditions was not provided oxygen as per the physician's order, with the concentrator set at higher levels than prescribed. The LPN and DON confirmed the discrepancy and adjusted the settings. The facility's policy requires adherence to physician orders for oxygen administration.
A facility failed to provide appropriate dialysis care for a resident with ESRD, as staff did not consistently complete post-dialysis assessments or maintain adequate communication with the dialysis center. The resident's care plan required specific actions, including monitoring the dialysis site, which were not consistently followed. The Unit Manager confirmed the lapses in completing the necessary documentation and communication.
The facility failed to ensure accurate labeling of medications for two residents, leading to discrepancies between the eMAR and medication labels. Nurses identified these discrepancies during administration and refrained from giving the medications, opting to seek clarification from physicians. The consultant pharmacist's audits did not include verifying eMAR against medication labels, contributing to the oversight.
A CNA failed to perform hand hygiene before donning gloves and improperly handled trash by bringing it into another resident's room, leading to a breach in infection control protocols. The DON confirmed these actions violated the facility's standards for preventing cross-contamination.
Failure to Conduct Medication Self-Administration Assessment
Penalty
Summary
The facility failed to conduct a medication self-administration assessment for a resident who was observed with a box of Ocusoft Retaine MGD ophthalmic emulsion at his bedside. The resident, who was admitted with diagnoses including a left tibia fracture, muscle weakness, and polyneuropathy, had a Brief Interview for Mental Status score of 15 out of 15, indicating cognitive intactness. Despite this, there was no physician's order for the eye drops, which the resident stated he used for his eyes. The primary RN acknowledged the presence of the eye drops and confirmed that there were no physician orders for them. The Director of Nursing stated that residents should have a completed self-administration assessment and a physician's order before self-administering medications. The facility's policy requires that residents who wish to self-administer medications must be assessed and determined capable of doing so, which was not done in this case.
Failure to Maintain Homelike Environment Due to Unrepaired Furniture
Penalty
Summary
The facility failed to maintain a homelike environment in one of the resident rooms, specifically room 103 in the East Wing. During observations on three separate occasions, it was noted that the first drawer of a nightstand was missing. The drawer had been removed and placed on top of a dresser, indicating it had been broken for some time. A Certified Nursing Assistant (CNA) confirmed that she had entered work orders to alert maintenance about the needed repair, but the issue remained unresolved. The Maintenance Director, upon being informed, acknowledged the problem and stated it was an easy fix, but he had not been aware of the issue prior to the surveyor's inquiry. A review of the work orders from January to April 2025 did not show any report about the broken drawer, suggesting a lapse in communication or documentation. The Administrator expressed that staff were expected to follow up with maintenance if repairs were not completed, either electronically or verbally, as per the facility's policy on plant operations and maintenance.
Inaccurate MDS Assessments for PASARR and Insulin Use
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the Pre-Admission Screening and Resident Review (PASARR) results for two residents with serious mental illness (SMI). Resident #6 was readmitted to the facility with diagnoses including schizoaffective disorder and bipolar disorder. Her annual MDS assessment incorrectly indicated that she did not meet the state definition of SMI, despite a PASARR Level II Determination Summary Report confirming otherwise. Similarly, Resident #8, who was readmitted with similar diagnoses, had two MDS assessments that inaccurately reflected her PASARR results, both indicating she did not have SMI when the PASARR report stated she did. The MDS Lead confirmed these discrepancies upon review. Additionally, the facility failed to accurately assess the use of insulin for Resident #97. The MDS admission assessment incorrectly documented the use of insulin, despite a review of the resident's physician orders and Medication Administration Record (MAR) showing no evidence of insulin administration. The MDS coordinator acknowledged the error after reviewing the MAR and confirmed that the resident did not receive insulin, indicating the MDS assessment was incorrect.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure the completion and accuracy of Level I Preadmission Screening and Resident Review (PASARR) documents for four out of five residents reviewed. Resident #49 was admitted with several diagnoses, including major depressive disorder, but the PASARR Level I Screen did not list any mental illness diagnoses. Similarly, Resident #79, who had multiple mental health diagnoses and was on psychotropic medications, also had a PASARR Level I Screen that did not reflect these conditions. The MDS Coordinator and the Director of Nursing (DON) acknowledged the omissions but indicated that the responsibility for updating the forms was unclear due to recent staff changes. Resident #23, admitted with diagnoses including schizophrenia disorder-bipolar type and PTSD, had a PASARR Level I Screen that did not include these diagnoses. The MDS Coordinator confirmed the oversight, and the Nursing Home Administrator (NHA) stated that the Assistant Director of Nursing (ADON) was responsible for PASARRs, but the ADON had recently resigned. Resident #34, admitted with similar mental health diagnoses, also had a PASARR Level I Screen that failed to list these conditions. The DON and MDS Coordinator both acknowledged the inaccuracies, and the NHA confirmed the ADON's responsibility for ensuring PASARR completion and accuracy. The facility's policy requires that each resident be screened for mental disorders or intellectual disabilities prior to admission. However, due to a lack of clear responsibility and recent staff transitions, the PASARR forms were not updated to reflect the residents' current diagnoses. This resulted in a failure to make necessary referrals for specialized services or alternative placements for residents with mental health conditions.
Failure to Follow Physician's Order for Oxygen Administration
Penalty
Summary
The facility failed to adhere to a physician's order for oxygen administration for a resident with acute respiratory failure, congestive heart failure, anemia, and shortness of breath. The resident was ordered to receive oxygen at 2 liters per minute (LPM) continuously via nasal cannula. However, observations revealed that the oxygen concentrator was set at higher levels, specifically 4 LPM and 3.5 LPM, during different times. This discrepancy was confirmed by both a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), who acknowledged the incorrect settings and adjusted the concentrator to the correct level. The LPN responsible for the resident's care indicated that her duties included checking the oxygen concentrator settings when administering medications and ensuring the nasal cannula was properly placed. Despite these responsibilities, the oxygen was not set according to the physician's order. The DON confirmed the expectation that nurses should verify the oxygen settings at the start of their shifts and periodically thereafter. The facility's policy on oxygen administration mandates that oxygen be administered as ordered by the physician, which was not followed in this instance.
Inadequate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with end-stage renal disease (ESRD) who required hemodialysis. The resident, who had moderately impaired cognition, reported that staff did not take vital signs or check her dialysis site upon her return from dialysis. The resident's care plan required the completion of a dialysis communication tool on dialysis days and a review upon return from dialysis, including monitoring for bruit and thrill at the shunt site. However, the facility did not consistently complete the necessary post-dialysis assessments as outlined in the care plan. The review of the Dialysis Communication Forms revealed that out of six dialysis sessions, only one session had all sections of the form completed. The forms for four sessions lacked post-dialysis assessments, and one form was missing entirely. The Unit Manager confirmed that the forms were not completed as required and acknowledged that the nurses were educated to complete the forms upon the resident's return from dialysis. Despite attempts to contact the dialysis center for missing information, the facility did not maintain adequate communication with the dialysis center, as required by their policy and procedure for hemodialysis.
Medication Labeling Discrepancies in LTC Facility
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled safely and accurately, as observed during medication administration for two residents. In one instance, a discrepancy was noted between the Electronic Medication Administration Record (eMAR) and the actual medication label for Eliquis, where the eMAR indicated a 5 mg dose, but the label instructed a 10 mg dose. The registered nurse did not administer the medication and opted to call the physician for clarification. In another case, discrepancies were found for a resident's medications, where the eMAR and medication labels did not match for Sodium Chloride and Levetiracetam, leading the licensed practical nurse to refrain from administering the medications and seek clarification from the physician. The report highlights that the facility's process for handling medication order changes was not consistently followed. Nurses explained that when orders were changed, they would update the order, reorder the medication, and remove the old blister pack from the cart. However, discrepancies in medication labeling persisted, as evidenced by the observations. The consultant pharmacist, who conducted monthly audits, did not verify the eMAR against the medication labels, which contributed to the oversight. The facility's policy required that medications with incorrect labels be returned to the pharmacy, but this was not adhered to, resulting in potential medication errors.
Infection Control Breach Due to Improper Hand Hygiene and Trash Handling
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices, as evidenced by the actions of a Certified Nursing Assistant (CNA) identified as J. On the morning of April 2, 2025, CNA J was observed donning gloves from a treatment cart without performing the required hand hygiene before entering a resident's room to assist with wound care. Later, CNA J acknowledged the importance of hand hygiene when donning and doffing gloves but admitted to forgetting this crucial step. In the afternoon of the same day, CNA J was seen holding a trash bag from a different room while standing at the doorway of another resident's room. He entered the room with the trash bag, which he later confirmed contained waste from a different resident's room. The Director of Nursing confirmed that this action was a breach of infection control protocols, as staff are expected to discard items removed from a resident's room in the soiled utility room and perform hand hygiene before entering another resident's room. This incident was recognized as a cross-contamination risk and a violation of the facility's infection control standards.
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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 Rockledge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sunrise Point Health And Rehabilitation Center | 0.3 mi | ★★★★★ | 2 | 2 |
| The Terrace At Courtenay Springs | 2.9 mi | ★★★★★ | 5 | 0 |
| Space Coast Healthcare And Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Merritt Island | 4.4 mi | ★★★★★ | 0 | 0 |
| Viera Healthcare And Rehabilitation Center | 6.6 mi | ★★★★★ | 7 | 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.