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 Sea Breeze Rehab And Nursing Center during CMS and state inspections, most recent first.
Informed consent for psychotropic medications was not properly obtained or documented for two residents. One resident with cognitive impairment and orders for lorazepam and trazodone had no consent form in the chart, despite repeated requests during survey, while another resident’s consent paperwork was incomplete and did not list the psychotropic medications or clearly indicate consent. The DON stated the facility had changed forms, but acknowledged the resident should have had documentation for each psychotropic medication added before the change.
Failure to Honor Resident Shower and Hygiene Preferences: Multiple residents with varying levels of cognitive and physical impairment did not receive showers or bathing care consistent with their care plans and stated preferences. Records showed missed or infrequent showers, inconsistent task documentation, and residents or family members reporting long gaps without bathing, while staff described unclear or inconsistent shower scheduling and documentation practices. Several residents stated they had not had a shower in weeks, and one resident was observed with dirty, greasy hair before later receiving a shower.
The facility failed to honor the shower preferences and schedules for two residents, leading to a deficiency in promoting resident self-determination. One resident, who was cognitively intact but later showed signs of confusion, received only three showers over a month despite being scheduled for twice-weekly showers. Another resident, also cognitively intact, did not receive any showers in the past month despite a similar schedule. Both residents expressed a desire for more frequent showers, and the DON confirmed the lack of documentation for showers or refusals.
The facility failed to maintain a safe, clean, and homelike environment in Unit B, as observed by surveyors. Issues included rusted IV poles, stained furniture, improperly wrapped call light cords, and debris under chair cushions. The Director of Maintenance acknowledged these findings during a facility tour.
A resident reported missing clothes after sending them to the laundry, but the facility failed to address the grievance. Despite informing staff, including the previous Social Worker and CNAs, no action was taken until the surveyor's involvement. The DON was unaware of the issue and acknowledged that no grievance had been filed, contrary to the facility's policy requiring prompt resolution of grievances.
The facility failed to ensure accurate MDS assessments for three residents. A resident was incorrectly coded as comatose, while two others had inaccuracies regarding dental and hearing status. These errors were identified through interviews and observations, revealing discrepancies between the MDS assessments and the residents' actual conditions.
The facility failed to develop care plans for two residents, one with hearing impairment and another self-administering medication. A resident with hearing issues had no care plan despite being identified as having impaired hearing. Another resident was allowed to self-administer Creon without a proper assessment or care plan, contrary to facility policy. Staff interviews revealed inconsistencies in the process for assessing and documenting self-administration capabilities.
The facility failed to document the removal of narcotics in the MARs for three residents, leading to discrepancies between the medication monitoring control records and the MARs. A resident with a physician order for Oxycodone HCl had undocumented medication removal on a specific date, while another resident with an order for Oxycodone Acetaminophen had missing documentation for a medication removal and administration. Additionally, a third resident with a Hydrocodone-Acetaminophen order had discrepancies in documentation, confirmed by the DON.
A resident with dementia and metabolic encephalopathy eloped from the facility, crossing a busy street to another nursing home. Despite documented wandering and exit-seeking behaviors, the incident was not recorded in the facility's logs, and the investigation was insufficient. Staff interviews revealed a lack of awareness of the resident's elopement risk, and the facility failed to determine how the resident exited the building.
Informed Consent for Psychotropic Medications Not Properly Documented
Penalty
Summary
The facility failed to ensure informed consent for psychotropic medications was obtained for two residents receiving such medications. One resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, generalized anxiety disorder, major depressive disorder, and brief psychotic disorder, and had a BIMS score of 9 indicating moderate cognitive impairment. Physician orders included lorazepam and trazodone, but the record contained no informed consent for psychotropic medications on admission, and multiple requests during the survey for the consent documentation were not met with any record provided. During observation, the resident was seen reclined in a Geri chair repeatedly calling out for help and attempting to get out of the chair, and later told the surveyor, "help me, I want to get out of this chair." The DON stated medical records, admissions, and MDS did not have the consent record. A second resident was admitted with diagnoses including major depressive disorder, anxiety disorder, COPD, hypertension, and muscle weakness, and had current and prior orders for psychotropic medications including Trileptal, fluoxetine, chlorpromazine, and trazodone. The chart contained a Psychoactive Medication Informed Consent form signed by the resident, but the form was incomplete because the statement indicating whether the resident wanted or did not want the medication was not checked and the medications were not listed. The record also contained a Psychotropic Medications Use: Risks vs Benefits document, and the DON stated the facility had stopped using the Psychoactive Medication Informed Consent form and used the Risk & Benefit form instead, while acknowledging the resident should have had documentation for each psychotropic medication added before that change.
Failure to Honor Resident Shower and Hygiene Preferences
Penalty
Summary
The facility failed to honor resident rights and resident choice related to bathing and showers for multiple residents. The report states that, based on observation, interview, policy review, and record review, the facility did not ensure showers and/or shower preferences were honored for 6 of 7 sampled residents: Residents #15, #40, #38, #81, #95, and #112. The facility policy required appropriate care and services for residents unable to perform ADLs independently, including bathing and showers, with resident consent and in accordance with the plan of care and resident preferences. Resident #15 had diagnoses including acute systolic heart failure, cardiomegaly, and an implanted cardiac defibrillator, and had a BIMS score of 10 indicating moderate cognitive impairment. His baseline care plan required limited to extensive assistance with bathing and showering, and he stated he had difficulty getting staff to give him a shower, had no scheduled shower day, and had only 1-2 showers during his stay. The shower task did not list days or shift, while a paper schedule in a binder listed Monday and Thursday on 3-11. Review of the past 30 days showed only 6 showers/baths, with only one on a scheduled shower day, and no refusals documented. Resident #38, who had diagnoses including COPD, muscle weakness, hip fracture, hepatic failure, hypoglycemia, and MI, had intact cognition and was assessed as needing partial/moderate assist for showers and baths, yet stated he had not had a shower in weeks and wanted one. Resident #81, with diagnoses including Parkinson’s disease, cervical spinal stenosis, depression, anxiety, muscle weakness, dysphagia, and hypertension, had intact cognition and a care plan calling for limited to extensive assist with bathing. Her shower task showed no showers or full baths for the prior 30 days, only 2 sponge baths, and she stated she had not had a shower in 3 weeks and cried when asked about it. Resident #112, who had diagnoses including hypothyroidism, CAD, hypertension, pulmonary embolism, cachexia, hemiplegia/hemiparesis following cerebral infarction, diabetes, COPD, Sjogren syndrome, heart failure, and vascular dementia, was dependent on staff for bathing and showers. Her shower/bath task sheet showed no showers or baths since admission, and she stated she had not had a shower and did not know it was an option; her hair was observed dirty and greasy before she finally received a shower later in the day. Resident #95, with diagnoses including paresthesia of skin, CHF, hypertension, pneumonitis, dysphagia, depression, and diabetes, had intact cognition and required substantial to maximal assist with showers. His shower task showed only one shower and two partial sponge baths over the review period, and he stated he had never been offered or given a shower before going to the hospital and could not have showers after returning because of a permanent plasma port. Resident #40, who had diagnoses including ischemic cardiomyopathy, chronic systolic CHF, depression, anxiety, mood disorder, and paranoid schizophrenia, had intact cognition and preferred showers as very important. Her care plan called for shower/bed bath per preference on shower days, but the CNA task showed only 5 showers, 2 full bed baths, and 12 entries marked not applicable, with a 2-week gap and no refusals documented. Her family member reported she sometimes went 3 weeks without showers or change of clothing, and the resident was observed in bed with oily, unclean hair and stated she had not received a shower that day and preferred morning showers. Resident #29, who had intact cognition and was dependent for toileting hygiene and clothing, stated staff told her they changed residents every two hours but she had to wait until a scheduled time even when she needed to be changed, and she reported staff turned off her call light and told her to wait.
Failure to Honor Resident Shower Preferences and Schedules
Penalty
Summary
The facility failed to honor the shower preferences and schedules for two residents, leading to a deficiency in promoting and facilitating resident self-determination. Resident #14, who was cognitively intact upon admission but later showed signs of cognitive confusion, was scheduled for showers twice a week but only received three showers over a thirty-day period. The resident expressed a desire for more frequent showers but was unaware of the shower schedule. The CNA responsible for Resident #14 stated that showers and refusals were documented in the computer, but the Director of Nursing confirmed the lack of documentation for showers or refusals. Similarly, Resident #48, who was cognitively intact and expressed the importance of choosing between a bath and a shower, did not receive any showers in the past thirty days despite being scheduled for showers twice a week. The resident reported having only one shower since November and expressed a desire for two to three showers a week. The CNA working with Resident #48 was unaware of the resident's shower schedule and did not offer a shower during the scheduled shift, instead providing a bed bath. The Director of Nursing also confirmed the lack of documentation for showers or refusals for this resident.
Facility Fails to Maintain Safe and Clean Environment in Unit B
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment in Unit B, as observed by surveyors on multiple occasions. On January 8th, an IV pole in one room was found to be rusted at its base. In another room, a resident's spouse reported that chairs in the sitting room next to the nurses' station were in poor condition, with trash and stained seats, which was confirmed by the surveyor's observations. Additionally, a bathroom door was noted to squeak, and a bedside table was stained with a white substance, with another IV pole also showing rust. Further observations revealed that the black caulking around a toilet base was coming away and had debris in the gap, a remote control was frayed, and a call light cord was improperly wrapped around a handrail, making it unusable. A privacy curtain between beds was stained with a brown substance. These findings were acknowledged by the Director of Maintenance during a facility tour, who noted that the black caulking was intended to match the floor and that the call light cord would be replaced.
Failure to Address Resident Grievance on Missing Personal Items
Penalty
Summary
The facility failed to respond to a verbal grievance regarding missing personal items for a resident, identified as Resident #13. The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15, reported missing clothes, including 8 dresses and 3 skirts, after sending them to the laundry. Despite the resident's attempts to inform the previous Social Worker and Certified Nursing Assistants (CNAs) about the missing items, the grievance was not addressed or documented by the facility. During an interview, the Director of Nursing (DON) expressed surprise upon learning about the missing clothes and acknowledged that no grievance had been filed for Resident #13. The resident confirmed having communicated the issue to staff members, but no action was taken to resolve the grievance. The facility's policy requires prompt efforts to resolve grievances, but in this case, the grievance was not addressed until the surveyor's involvement.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents. Resident #14 was incorrectly coded as comatose in the MDS assessment, despite no evidence supporting this status in the medical record. The error was attributed to the previous Social Service Director, who was no longer employed at the facility. The current MDS Coordinator, who was new to the facility, was unaware of the error until it was brought to her attention. Resident #82's MDS assessment inaccurately documented the resident as having natural teeth, while observations and interviews confirmed the resident was edentulous, with only metal posts in place. Similarly, Resident #87's MDS assessment inaccurately documented adequate hearing and the presence of natural teeth, despite the resident reporting significant hearing impairment and being observed without teeth. These inaccuracies were identified during interviews and observations, highlighting discrepancies between the MDS assessments and the residents' actual conditions.
Deficiencies in Care Planning for Hearing and Medication Self-Administration
Penalty
Summary
The facility failed to develop and implement care plans for two residents, leading to deficiencies in addressing their specific needs. Resident #87, who was admitted with a diagnosis including Wedge Compression Fracture and Muscle Weakness, was identified as having impaired hearing during the admission evaluation. However, no care plan was developed to address her hearing concerns, despite her stating she was deaf in one ear and had limited hearing in the other. The MDS Coordinator acknowledged the absence of a care plan for hearing issues, which should have been in place. Resident #15, who was cognitively intact with a BIMS score of 14, was allowed to self-administer Creon, an enzyme replacement medication, without a proper assessment or care plan. The facility's policy required an assessment by the Attending Physician and the Interdisciplinary Care Planning Team to determine the resident's capacity to self-administer medication safely. However, there was no documented assessment or care plan for Resident #15's self-administration of Creon, and the medication administration record indicated unknown self-administration. The B-Unit Manager admitted to completing an assessment on paper due to computer issues, but it lacked necessary details and evidence of IDT participation. Interviews with staff revealed a lack of clarity and consistency in the process for assessing and documenting residents' ability to self-administer medication. The Regional Clinical Consultant confirmed that the process should involve a nursing assessment followed by care planning with the IDT, but this was not documented for Resident #15. The absence of proper documentation and care planning for both residents highlights deficiencies in the facility's ability to meet the residents' needs effectively.
Failure to Document Narcotic Removal in MARs
Penalty
Summary
The facility failed to ensure proper documentation of narcotic removal in the medication administration records (MARs) for three residents. Resident #28 had a physician order for Oxycodone HCl to be administered via peg-tube every four hours as needed for chronic pain. However, there was a discrepancy between the medication monitoring control record and the MARs, as the removal of the medication on January 3rd at 10:57 AM was not documented in the MARs. Similarly, Resident #6 had a physician order for Oxycodone Acetaminophen for non-acute pain, but the MARs lacked documentation for the removal and administration of the medication on January 4th at 6:30 PM. Resident #9 had a physician order for Hydrocodone-Acetaminophen for non-acute pain, with discrepancies noted between the medication monitoring control record and the MARs. The MARs did not document the removal and administration of the medication on January 1st at 8:15 PM. An interview with the Director of Nursing confirmed the lack of documentation for the narcotic removal, indicating a failure in maintaining accurate medication records for these residents.
Failure to Prevent Elopement and Inadequate Investigation
Penalty
Summary
The facility failed to prevent an elopement incident involving a resident with a history of dementia, metabolic encephalopathy, and alcohol abuse. The resident, who was assessed as a low risk for elopement, exhibited wandering and exit-seeking behaviors. Despite these behaviors being documented in progress notes, the resident managed to leave the facility without staff knowledge and supervision, crossing a busy street to another nursing facility. The incident was not captured in the facility's incident log, and the investigation conducted was inadequate. The facility did not identify the event as an elopement, and the investigation failed to determine how the resident exited the building. Interviews with staff revealed a lack of awareness regarding the resident's elopement risk, and the surveillance video was not properly utilized to ascertain the details of the incident. The facility's failure to thoroughly investigate the root cause of the elopement and to report the adverse event as required by state and federal regulations contributed to the deficiency. Additionally, the care plan was not updated with appropriate interventions, such as one-to-one supervision, to prevent future occurrences.
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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 Vero Beach
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Vero Beach Care Center | 0 mi | ★★★★★ | 2 | 0 |
| Palm Garden Of Vero Beach | 0.1 mi | ★★★★★ | 3 | 0 |
| Hidden Lakes Senior Living Community | 0.6 mi | ★★★★★ | 12 | 0 |
| Garden View Health And Rehabilitation Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Willowbrooke Court At Indian River Estates | 5.5 mi | ★★★★★ | 0 | 0 |
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