Melbourne Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, and interview, the facility failed to store food in accordance with professional standards for food service safety and failed to follow proper sanitation practices to prevent the outbreak of foodborne illness. This had the potential to affect all residents at the facility who eat food prepared in the kitchen.

Inspectors wrote3. Review of resident #25's record revealed an admission date of 11/23/23. His diagnoses include unspecified atrial fibrillation, acquired absence of right leg below knee, and acquired absence of left leg below knee. His quarterly 11/29/24 Minimum Data Set included a Brief Interview of Mental Status score of 15/15, which indicated intact cognition. On 3/03/25 at 11:05 AM, resident #25 said he had a skin growth on the left side of his nose since his admission to the facility in 2023. He explained in October 2024 he requested help from the facility's Business Office Manager to recertify his health insurance, Medicaid. He said the dermatology group that visited the facility did not take the type of Medicaid he had when he attempted to be seen by them last year; so, he waited for a dermatology visit to be arranged with an outside provider who took his insurance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment by failing to de-emphasize the institutional character of the dining room for one of one dining room reviewed for dining and failed to maintain a sanitary and comfortable interior of the resident rooms for 3 of 3 residents rooms reviewed for cleanliness, (#13, #20, and #62).

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the nursing staffing hours daily, which identified the number of staff working in the facility on the form posted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system for the prevention of communicable diseases by failing to ensure all residents were offered and encouraged to perform hand hygiene before meals for all residents eating meals in the dining room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct a medication self-administration assessment to ensure safety for 2 of 2 residents reviewed for self-administration of medications, of a total sample of 62 residents, (#44, and #92).

Inspectors wrote2. Resident #26 was initially admitted to the facility on [DATE] with a diagnosis of metabolic encephalopathy. She was discharged from the facility on 4/26/24 and readmitted on [DATE] following a right hip fracture. The admission Record or face sheet listed diagnoses including dementia with behavioral disturbances, insomnia, depression, and psychotic disorder with delusions due to known physiological condition, and anxiety. A psychiatry consult from 6/26/24 revealed that resident #26 was admitted with medications for diagnoses of dementia and insomnia. Resident #26 was started on Depakote sprinkles 250 milligrams (mg) two times a day for psychotic disorder on 1/02/24. Resident #26's care plan initiated on 7/12/24 indicated the resident had impaired cognition which affected communication, functional abilities, decision making, and judgement related to psychosis and dementia. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 8 residents reviewed for choices, of a total sample of 62 residents, (#93).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice, and per physician orders for 2 out of 2 residents reviewed for respiratory care, of a total sample of 62 residents, (#35, & #85).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Pharmacist recommendations were addressed by the physician for 1 of 5 resident reviewed for unnecessary medications, of a total sample of 62 residents, (#57).

Inspectors wroteBased on interview, and record review, the facility failed to ensure an allegation of neglect was reported to the relevant State Agencies within the regulatory timeframe for 1 of 2 resident reviewed for Abuse and Neglect, (#1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect by not ensuring staff implemented measures to mitigate risks to prevent elopement for 1 of 5 residents reviewed for elopement, of a total sample of 6 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury, harm, and/or death. While resident #1 was out of the facility unsupervised, there was likelihood he could have sustained serious life-threatening injuries, become lost, been accosted by unknown persons, drowned, or hit by a motor vehicle or high speed train and died. On [DATE] at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and a secure environment to prevent elopement for 1 of 5 residents reviewed for Elopement, of a total sample of 6 residents, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious life-threatening injury, harm, or even death. While resident #1 was out of the facility unsupervised, there was likelihood he could have sustained serious life-threatening injuries, become lost, been accosted by unknown persons, drowned, or hit by a motor vehicle or high speed train and died. On [DATE] at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. [...]

Inspectors wroteBased on observation, and interview, the facility's administration failed to implement it's resources to maintain effective elopement prevention measures to ensure the safety of residents known to be at high risk of elopement. On 10/26/24 at approximately 8:05 PM, a physically and cognitively impaired resident exited the facility's front entrance when an unknown staff person unlocked the door and allowed him to leave the facility unsupervised. Resident #1 wandered through the parking lot in the dark, crossed a two lane road, and proceeded approximately 0.7 miles along a four lane road with moderate traffic at speed limits of 35 miles per hour. The route along the way had uneven terrain and curbs. Approximately 0.1 miles from the facility was a large lake, and approximately 0.4 miles, there was a high speed railroad crossing. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure a Do Not Resuscitate Order (DNRO) form was signed and properly completed for 1 of 1 resident reviewed for advanced directives from a total sample of 36 residents, (#52).

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening And Resident Review (PASARR) for a later identified Mental Illness (MI) for 1 of 1 resident reviewed for PASARR from a total sample of 36 residents, (#52).

Inspectors wroteBased on interview and record review, the facility failed to complete a Preadmission Screening and Resident Review (PASARR) level I for possible Serious Mental Illness (SMI) for 1 of 1 resident from a total sample of 36 residents (#55).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care and services to maintain or prevent decline in Activities of Daily Living (ADL) abilities, for 1 of 3 residents reviewed for Rehabilitation and Restorative services from a total sample of 36 residents, (#98).

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a physician order for oxygen therapy for 1 of 1 resident reviewed for oxygen of a total sample of 36 residents, (#79).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure behavior monitoring and side effects of antipsychotic medication were documented for 2 of 5 residents reviewed for unnecessary medications out of a total sample of 36 resident, (#55, #67).

Inspectors wroteBased on interview, and record review, the facility failed to ensure psychotropic medications that were ordered as needed (PRN), did not exceed beyond 14 days without documented rationale for 1 of 5 residents sampled for unnecessary medications of a total sample of 36 residents, (#55).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the kitchen pantry and the walk-in cooler were clean and in good repair, and failed to ensure the walk-in freezer was maintained to prevent the potential of food contamination. The facility also failed to use non-expired sanitizing strips to ensure proper concentration of the sanitizer in the manual washing sinks.