Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 West Melbourne Health & Rehabilitation Center during CMS and state inspections, most recent first.
A facility failed to respond in writing to repeated Resident Council grievances about staffing, staff customer service, dietary issues, and shower room cleanliness. Residents said the same concerns were raised month after month without resolution or feedback, while the Activity Director and NHA confirmed the issues were discussed verbally in morning management meetings and handed off to dept heads, but were not documented on grievance forms as required by policy.
Kitchen sanitation and food storage deficiencies: The kitchen floor, shelves, prep surfaces, and equipment were observed dirty with stuck-on food, sticky residue, and burnt food. Food items were improperly stored, including defrosted chicken over meat juices, expired items left in the refrigerator, open frozen items with freezer burn, and dry goods left open and undated. Ants were observed on an unclean shelf, and the Kitchen Mgr and Maintenance Dir confirmed the conditions.
QAA/QAPI oversight failed to sustain prior improvement measures, and repeat deficiencies were cited for ADL care, respiratory care, and sanitary food service. The facility’s QAPI plan called for using past survey findings to identify issues, implement interventions, assess results, and sustain improvements, but the same areas were cited again for missed oral care and showers, CPAP-related respiratory care issues, and unsanitary food handling with dirty surfaces, insects, opened and undated food, and improper meat thawing. The Administrator said staff and management changes had occurred and some things had been dropped, while acknowledging QAPI plans were supposed to continue.
A resident with severe cognitive impairment was discharged with a positive account balance, but the facility did not refund the balance to the resident's representative within the required timeframe. Despite repeated requests and confirmation of the refund amount, the facility delayed issuing the refund, citing pending payments from Medicaid.
Failure to promote dignity during assisted dining occurred when staff stood while feeding a cognitively intact resident with quadriplegia and dysphagia, despite his preference for staff to sit at eye level during meals. The resident was totally dependent for ADLs and meals, the care plan directed staff to allow adequate time for meals, and interviews confirmed CNAs often stood because of chair availability or room setup; the resident’s reported preference for standing while he watched TV was not documented in the care plan.
A resident with Parkinsonism, COPD, neuropathy, and mild cognitive impairment did not receive bank or facility financial statements for her trust account. Staff confirmed quarterly statements were supposed to be mailed to the resident or POA, but the POA address was not updated and there was no evidence the resident or POA received statements. The resident also requested a copy of her account statement and said she did not know whether she had enough funds for a personal service.
Failure to Maintain Clean Shower Rooms: A resident reported a black substance in a B-Wing shower room, and surveyors observed black substance on the ceiling and vent in one shower room and a similar substance near the shower area in another. The Housekeeping Director said the condition was not acceptable and that shower rooms were expected to be clean, while the Maintenance Director said he was unaware of the issue and had not been notified. The Administrator reviewed the photo and confirmed the shower rooms should be kept clean.
Failure to promptly resolve and communicate a grievance about damaged personal property. A cognitively intact resident with quadriplegia, dysphagia, and DM2 reported that staff broke his personal TV while moving his dresser during a room transfer. Although the grievance paperwork noted the TV would be reimbursed, the resident was not kept informed of progress and the grievance was not handled promptly, with the SSD and NHA acknowledging the delay and that the grievance process was not followed.
A resident with severe cognitive impairment and dementia with psychotic disturbances received Quetiapine, but the comprehensive care plan for antipsychotic use was not developed after the admission MDS, and pharmacy recommendations were not incorporated. Another resident with active paranoid schizophrenia and severe cognitive impairment had no care plan for schizophrenia with anxiety and potential for complications until the last day of survey; the MDS Coordinator acknowledged the problem was missing from the care plan.
Failure to Provide Timely ADL Assistance and Documentation: Two residents did not receive consistent help with hygiene and bathing. One resident with quadriplegia reported CNAs did not routinely provide oral care, and a CNA confirmed teeth brushing was not done during care. Another resident with stroke-related weakness reported going weeks without a shower or bed bath, and record review showed multiple scheduled showers were not documented, with missing shower sheets and no nursing documentation of refusals.
Failure to implement the recommended RNP for a resident with Parkinsonism, COPD, neuropathy, schizoaffective disorder, and moderate cognitive impairment. PT discharged the resident with an FMP/RNP for AROM, bed mobility, and sliding-board transfers, but the record lacked evidence that the later recommended exercises were provided. The RNP nurse could not confirm services were completed, refusals were not documented, and the restorative plan was not incorporated into the care plan.
Failure to Obtain Physician Order for CPAP Use: A resident with COPD, respiratory failure with hypoxia, and sleep apnea had CPAP documented in notes and was using continuous O2, but no physician order for CPAP was in the chart. Staff interviews and record review showed the CPAP machine was in the room, the resident said it had not been connected since admission, and nursing had not obtained an order until it was later noticed by the UM.
Failure to Provide Trauma-Informed Care: A cognitively intact resident with PTSD, anxiety, and depression reported a history of sexual assault and ongoing flashbacks and nightmares, and stated that seeing a male resident who resembled one of her attackers sometimes brought back bad memories. The record showed trauma history and identified triggers such as cologne scents, lighting, and loud noises, but the comprehensive care plan did not include trauma-informed interventions, emotional support, or guidance for staff to help the resident cope.
Failure to Document and Respond to Resident Council Grievances
Penalty
Summary
The facility failed to respond in writing to repeated grievances identified by the Resident Council over a six-month period from June through November 2025. During a Resident Council meeting on 12/02/25, members confirmed they met monthly and stated that concerns about nurse and aide staffing, staff customer service, and dietary issues were voiced month after month without resolution. The residents in attendance stated that no one ever responded to the grievances or informed them what had been done. Review of the grievance log showed only one grievance from the Resident Council dated 11/12/25 regarding staff being loud, rude, and on their cell phones in the dining room. Resident Council minutes from June through November 2025 showed repeated concerns about staff using cell phones, and there were also repeat grievances about the cleanliness of the shower rooms. The Activity Director stated she attended every Resident Council meeting, helped facilitate discussion, and that concerns were discussed in the daily morning management meeting and handed off to department heads, but she confirmed this was done verbally with no written documentation. The Nursing Home Administrator stated his expectation was for the concerns to be brought to the morning meeting and then given to the appropriate department head, and he acknowledged the Resident Council concerns were not written up into a grievance form to show how or if they were addressed. The facility policy stated verbal grievances, including those raised during Resident Council meetings, should be recorded on a grievance form by the staff member who received the grievance.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to maintain the overall cleanliness of the kitchen and failed to ensure food was stored and distributed in a sanitary manner. During an initial kitchen tour with the Kitchen Manager, the floor was observed to be unclean with stuck-on food under tables and equipment, and shelves below the steam table had sticky residue and stuck-on food. Spice bottle lids on a prep table were visibly dirty, sticky, and crusted with spice flakes and residue, and a half-empty container of food thickener and a container of breadcrumbs were covered in an unknown substance. When these containers were lifted, ants were seen crawling all over the uncleaned shelf beneath them. The Kitchen Manager stated the floors were cleaned nightly and shelves were wiped daily, but she was unsure when maintenance had last power washed the floors. Further observation found the oven dirty with burnt food on the doors and inside. In the walk-in refrigerator, a tray with meat juices was dripping onto the floor and a box of defrosted chicken was stored on top of it. Also in the refrigerator were a container of fruit punch dated to be used prior to 11/30/25 and a stainless-steel container of orange sauce labeled to be used prior to 11/28/25, both of which had not been discarded. In the walk-in freezer, a box of sausage patties and a box of frozen empanadas were left open to air and had freezer burn. In the dry storage closet, open items including a bag of sugar, box of potato pearls, and package of gravy mix were not appropriately closed and were not dated, and the floor had dried, crusted food around the shelf legs. The Kitchen Manager and Maintenance Director confirmed the cleaning practices and the condition of the kitchen areas, including that the kitchen floors had been power washed on 11/19/25 and needed to be cleaned.
QAPI Oversight Failed to Sustain Prior Improvements
Penalty
Summary
The facility failed to ensure its QAA/QAPI committee conducted performance improvement activities to sustain prior improvement measures. The facility’s QAPI plan stated it would gather information from sources including past surveys, identify and clarify issues, design and implement interventions, assess results, and sustain improvements using a root cause process. During the previous recertification survey, deficiencies were cited at F677 for ADL care not provided to a dependent resident related to nail care, at F695 for tracheostomy care and oxygen therapy not provided as ordered, and at F812 for food storage, preparation, and service not being sanitary. During the current survey, the facility was again cited at F677 for ADL care not provided to a dependent resident related to oral care and showers, at F695 for respiratory care related to use of a CPAP machine, and at F812 for unsanitary food storage, preparation, and service related to dirty surfaces, insects, opened and undated food, and improper defrosting of meat products. The repeat deficiencies showed there was insufficient auditing and oversight to prevent the citations. The Administrator stated that staff and management changes had occurred and that some things had been dropped, while acknowledging that QAPI plans were supposed to continue despite staff changes.
Failure to Timely Refund Discharged Resident's Positive Account Balance
Penalty
Summary
The facility failed to refund a positive account balance to a discharged resident or their representative within 30 days of discharge, as required by regulations. The resident, who had severe cognitive impairment due to Alzheimer's Disease and other medical conditions, was discharged home with Medicaid as the primary payor. Despite multiple requests from the resident's guardian and confirmation of the refund amount and address, the facility did not issue the refund in a timely manner. Facility staff acknowledged the existence of a positive balance in the resident's account and confirmed that the refund had not been processed. The business office staff indicated that their usual practice was to wait until all payor sources had paid before issuing refunds, and at the time of review, some claims remained open. The facility's own policy stated that refunds would be issued in accordance with state and federal guidelines, but this was not followed in this case.
Failure to Promote Dignity During Assisted Dining
Penalty
Summary
The facility failed to promote dignity during dining for a resident with quadriplegia, dysphagia, and type 2 diabetes who was cognitively intact and totally dependent on staff for all ADLs except toileting hygiene. The resident’s care plan identified that he was dependent on staff for all meals and directed nursing staff to allow adequate time for meals to be consumed. During observation, a female staff member was seen standing while feeding the resident lunch, and there was no chair in the room for staff to sit during the meal. The resident stated that a chair had been removed from his room a few weeks earlier because his roommate’s wheelchair did not fit, and it was not replaced. He reported that CNAs normally stood while feeding him and that he preferred staff to sit while assisting with meals because it allowed them to take their time due to his swallowing difficulties. Staff interviews confirmed that CNAs sometimes stood while feeding him, that chair availability affected whether they sat, and that the resident’s preference for staff to stand while he watched television was not documented in the care plan. The DON confirmed that any deviation from standard care should be included in the individualized care plan, and this preference was not documented.
Resident Trust Account Statements Not Provided
Penalty
Summary
The facility failed to properly hold, secure, and manage a resident’s personal money that was deposited with the nursing home, and failed to follow generally accepted accounting principles in the management of resident personal funds for one resident reviewed. The resident had diagnoses including Parkinsonism, COPD, and neuropathy, and a quarterly MDS assessment showed a BIMS score of 12 out of 15, indicating mild cognitive impairment. The resident stated she had not received bank statements or the facility’s financial statements and said she wanted monthly statements so she would know her balance, including whether she had enough funds to pay for her hair appointment. The financial specialist assistant stated she managed resident trust accounts and that quarterly statements were mailed to residents or their representatives, but confirmed the resident had a trust account and that the facility had learned earlier in the year that the resident had an external bank account and received a VA pension. The facility assisted with transferring those funds into the resident trust account and with reapplying for Medicaid, and a POA was added to manage the resident’s affairs. The financial specialist assistant stated she failed to mail statements to the POA because the address on file listed the resident and the facility’s address, and she was unable to provide evidence that the resident or POA received any quarterly statements during the year. Another staff member stated the resident requested a copy of her trust account statement but it had not yet been provided, and the resident rights packet stated financial records would be available through quarterly statements and upon written request.
Failure to Maintain Clean Shower Rooms
Penalty
Summary
The facility failed to provide maintenance and housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior in 2 of 2 shower rooms on the B-Wing. A resident reported a black substance above the door in one of the shower rooms. During observation with the Housekeeping Director, a black substance was seen on the ceiling near the air conditioner vent and on the vent itself in the east individual shower room, and a similar substance was observed near the shower area in the north-side individual shower room. The Housekeeping Director stated the condition was not acceptable and said shower rooms were expected to be clean, while also explaining that housekeeping staff cleaned the vent exterior and maintenance staff handled the ceiling. The Maintenance Director stated he was unaware of the black substance in the east individual shower room and said no one had reported the condition. He explained the substance was caused by dust mixed with condensation from the vent and stated his expectation was for shower rooms to be clean and homelike for residents. The Administrator reviewed the photograph of the shower room and confirmed he expected the shower rooms to be kept clean. The facility policy titled Resident Environment Quality stated its purpose was to protect the health and safety of residents, personnel, and the public and directed that preventive maintenance schedules for the building and equipment be followed to maintain a safe environment.
Failure to Promptly Resolve and Communicate a Grievance About Damaged Personal Property
Penalty
Summary
The facility failed to follow its grievance process for a resident with intact cognition who had a grievance about his personal property. Resident #20, who had diagnoses including quadriplegia, dysphagia, and type 2 diabetes, stated that while staff were moving his dresser during a room transfer, his 55-inch smart TV fell and broke. He reported that the TV had cost approximately $1,600 and that he provided a purchase receipt when asked for replacement purposes. He also stated that the Social Services Director later told him the Administrator said the amount was too much to reimburse for a TV. The grievance documentation showed the concern was that the resident’s personal TV was knocked over and broken during care, and staff confirmed they were giving care and broke the TV. The form stated the resident would be reimbursed and was signed by the Social Services Director, and later paperwork requested payment for the broken TV. However, the resident was not kept apprised of the progress toward resolution, and the facility did not make a prompt effort to resolve the grievance. The Social Services Director acknowledged there should have been timely follow-up and documentation regarding the grievance status, and the Administrator acknowledged the grievance process was not followed and that it took too long to resolve the issue.
Missing Care Plans for Antipsychotic Use and Schizophrenia
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident who was readmitted with hypertensive heart disease without heart failure, Alzheimer’s disease, dementia with psychotic disturbances, major depressive disease, and anxiety. The resident’s admission MDS assessment showed a BIMS score of 3 out of 15, indicating severe cognitive impairment, and identified use of high-risk medications including antipsychotics, anti-anxiety medications, and antidepressants. The electronic medication record showed an order for Quetiapine 25 mg twice daily for dementia with psychotic disturbances, but a comprehensive care plan for antipsychotic medication was not developed after the admission MDS assessment. A pharmacy recommendation dated 11/04/25 advised the interdisciplinary care plan include identifying common behavioral expressions, implementing and reassessing person-centered interventions, and discussing the appropriateness of the current dose with the provider. During interview, the MDS Coordinator stated the comprehensive care plan was not finished yet, acknowledged it needed to be completed within seven days of the admission assessment, and confirmed she did not review the pharmacy recommendation because it was not passed along to her. The facility also failed to develop an individualized care plan for a resident with active paranoid schizophrenia. The resident’s record showed diagnoses including diffuse traumatic brain injury, major depressive disorder, persistent mood disorders, brief psychotic disorder, mood affective disorder, generalized anxiety disorder, pseudobulbar affect, and paranoid schizophrenia, and the quarterly MDS showed severe cognitive impairment with high-risk medications. The care plan report showed no plan for schizophrenia with anxiety and potential for complications until the last day of the survey, and the MDS Coordinator stated the missing problem should have been included in the care plan.
Failure to Provide and Document ADL Assistance
Penalty
Summary
The facility failed to ensure proper and timely assistance with ADLs for two residents, including assistance with oral care and bathing. Resident #20 was admitted and later readmitted with quadriplegia, dysphagia, and type 2 diabetes, and his MDS showed he was cognitively intact but totally dependent on staff for nearly all ADLs. His care plan required total assistance related to quadriplegia and included brushing his teeth and providing oral care, with a facility policy stating oral hygiene was to be provided twice daily unless contraindicated or declined. During interview, the resident stated CNAs did not routinely brush his teeth and only did so occasionally if he requested it, and a CNA confirmed she had not brushed his teeth during care and acknowledged oral care was not provided. Resident #143 was admitted and later readmitted with hemiplegia/hemiparesis following a stroke, rheumatoid bursitis of the left elbow, hearing loss, and type 2 diabetes. His MDS showed mild to moderate cognitive impairment and need for partial to moderate assistance with showers and transfers. His care plan directed bathing per schedule and assistance as needed, and the shower list instructed staff to sign off as showers were given and to provide mouth care twice daily. The resident reported going about three weeks without a shower or bed bath before the prior week and said showers resumed only after he complained about feeling unclean. Record review and staff interviews showed missing or incomplete documentation for scheduled showers, including no evidence of showers on multiple scheduled dates and missing shower sheets for two dates. The CNA stated showers were documented electronically and on shower sheets but could not explain why showers were not documented as completed. The LPN stated CNAs were required to sign shower sheets and notify the nurse if a resident refused care, with nurses responsible for documenting refusals, yet progress notes did not show refusals of showers. The UM and DON confirmed there was no evidence the resident received showers on several scheduled days and acknowledged the POC did not include documentation of whether a shower or bed bath was provided.
Failure to Implement Restorative Nursing Services
Penalty
Summary
The facility failed to implement the recommended Restorative Nurse Program (RNP) to provide mobility and range of motion (ROM) services for one resident who had been readmitted with diagnoses including Parkinsonism, insomnia, chronic obstructive pulmonary disease, neuropathy, and schizoaffective disorder. The resident’s MDS assessment showed moderate cognitive impairment, dependence for several activities of daily living, wheelchair use for mobility, and no therapy services or RNP during the look-back period. The resident stated she had previously benefited from therapy and did not recall receiving RNP services after therapy ended. The resident’s PT discharge summary documented that therapy established a long-term goal to train nursing with a Functional Maintenance Plan (FMP) and RNP. CNA training in slide-board transfers was completed, and discharge recommendations stated the resident was to be discharged to nursing care with an FMP and RNP. The PT FMP forms included AROM and bed mobility exercises, with a later FMP adding functional transfers out of bed using a sliding board. However, the resident’s POC history showed only limited documentation of AROM and bed mobility earlier in the year, and there was no evidence in the medical record that the therapy-recommended exercises initiated later were provided. The RNP nurse stated she was responsible for implementing FMPs, that RCNAs were expected to perform and document the services, and that residents who refused were to be reported to her, though refusals were not always documented. She acknowledged that resident refusals and RNP sessions were not documented, that she could not confirm whether the resident received the recommended services, and that she did not recall documenting the resident’s progress or discharge from the RNP. The resident’s restorative observation report did not include restorative goals or a restorative plan, and the restorative program was not incorporated into the comprehensive care plan. The facility policy required review of FMPs, daily documentation of restorative services, and updating the care plan as needed.
Failure to Obtain Physician Order for CPAP Use
Penalty
Summary
The facility failed to obtain physician orders for respiratory treatments for resident #33, who was admitted with acute and chronic respiratory failure with hypoxia, COPD, type 2 diabetes, and cor pulmonale. The resident’s MDS showed intact cognition, shortness of breath with exertion, use of a manual wheelchair, and continuous oxygen therapy. Her pre-admission physician note documented use of a CPAP machine at night for obstructive sleep apnea and obesity hypoventilation syndrome, and the care plan addressed respiratory complications and oxygen therapy. During the stay, staff documented that the resident slept with CPAP at night and that she was on oxygen, but the physician order record contained no order for CPAP use. The resident stated she had not used her CPAP since admission because it had not been connected and that she expected nursing staff to address it. Survey observations and interviews showed the CPAP machine was present in the room, staff were aware the resident said she needed it, and the unit manager stated a physician order for CPAP was not obtained until the machine was noticed later during care, after which she said the expectation would have been for nursing to question its use, review the record, and obtain an order.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to ensure that a resident who experienced trauma received trauma-informed care. The resident was admitted with diagnoses including type 2 diabetes and obstructive sleep apnea, and the facility later added generalized anxiety disorder, PTSD, and major depressive disorder. The MDS annual assessment showed a BIMS score of 15/15, indicating the resident was cognitively intact, and PTSD was listed among the diagnoses. The EMR also contained a trauma-informed care observation documenting that the resident had personally experienced a natural disaster, witnessed an assault with a weapon, and was a victim of sexual assault. During interview, the resident reported that she and her sister were sexually assaulted by their stepfather and uncle when they were minors, and that she still had flashbacks and nightmares related to those events. She stated that a male resident in the facility resembled one of her attackers and that seeing him sometimes brought back bad memories. Review of the comprehensive care plan showed no trauma-informed care plan had been developed to address emotional support, identify triggers, or instruct staff on how to help her cope with her emotions. Psychiatric notes identified triggers such as certain scents of cologne, lighting, and loud noises, and recommended adding PTSD to the care plan with a quiet, consistent environment and supportive therapy, but no care plan addressing the trauma, interventions, or psychosocial support had been added. The SSD acknowledged that the resident should have had a comprehensive care plan for PTSD and trauma-related triggers.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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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) |
|---|---|---|---|---|
| Indian River Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Melbourne Terrace Rehabilitation Center | 2.4 mi | ★★★★★ | 0 | 0 |
| Avante At Melbourne Inc | 2.5 mi | ★★★★★ | 0 | 0 |
| Melbourne Healthcare And Rehabilitation Center | 2.6 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Melbourne | 2.7 mi | ★★★★★ | 2 | 0 |
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