Nursing & Rehabilitation Center of Melbourne

Inspectors wroteBased on interview, and record review, the facility failed to ensure proper indwelling urinary catheter care and monitoring was provided to 1 of 3 residents reviewed for catheter, of a total sample of 5 residents, (#2).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete antibiotic stewardship program for 3 of 4 residents reviewed (#117, #81, and #21) of a total sample of 55 residents and failed to ensure linens and laundry were handled, stored, processed, and transported safely to prevent the spread of infection to the extent possible in accordance with accepted national standards of practice.1. Resident #117 was admitted to the facility on [DATE] from the hospital with diagnoses including chronic pressure ulcer of right ankle with necrosis of muscle, osteomyelitis, peripheral vascular disease, and type 2 diabetes. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure residents received meals at an appetizing temperature.

Inspectors wroteBased on observation and interview, the facility's Administration failed to provide resources and equipment to ensure meals were delivered at palatable temperatures.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Quality Assessment & Assurance (QAA) / Quality Assurance and Performance Improvement (QAPI) committee conducted performance improvement activities to ensure prior improvement measures were sustained. Review of the facility's survey history revealed repeat deficiencies related to accuracy of assessments, quality of care and infection control during the current survey ending on 11/02/23. Past deficiencies revealed systemic concerns with similar findings on the previous recertification survey dated 11/2/23. On 11/20/25 at 6:15 PM, the Nursing Home Administrator (NHA) indicated repeat deficiencies regarding infection control, and quality of care were different from the issues from the previous survey. Their current Performance Improvement Plan (PIP) initiated from February 2025 and still ongoing included hand hygiene; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected Pre-admission Screening and Resident Review (PASARR) results for 1 of 6 residents reviewed for PASARR of a total sample of 55 residents, (#94).

Inspectors wroteBased on interview and record review, the facility failed to notify the State mental and intellectual disability authority after a significant change in the resident's mental condition for 1 of 6 residents reviewed for Pre-admission Screening and Resident Review (PASARR) of a total sample of 55 residents, (#94).

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for 1 out of 1 resident of a total sample of 55 (#164). Resident #164 was readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease, major depressive disorder, anxiety disorder, nicotine dependence, cigarettes, uncomplicated dependence on supplemental oxygen and chronic pain syndrome. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed resident #164 was cognitively intact with a brief interview of mental status score (BIMS) of 15 out of 15. Review of the smoking assessment listed resident #164 as a safe smoker on 4/15/24 it also included the verbiage smoking is always supervised; the smoking attendant holds cigarettes and lighter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement resident-directed care and treatment consistent with the resident's physician orders for 1 out of 2 residents, (#164), failed to ensure medications were administered and provided per physician orders to prevent missed doses in accordance with professional standards of practice for 1 of 1 residents, (#99), reviewed for quality of care, out of a total sample of 55 residents. Resident #99, a [AGE] year-old male, was admitted to the facility on [DATE] from an acute care hospital with diagnoses that included acute transverse myelitis in demyelinating disease of central nervous system, generalized anxiety disorder, and major depression. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain timely dressing change orders for a peripherally inserted central catheter (PICC), failed to timely change the PICC dressing, failed to obtain timely intravenous (IV) flush orders, and failed to administer the IV flushes in accordance with accepted standards of practice for 1 of 1 residents reviewed for IV antibiotics in a total sample of 55 residents (#52).

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide ongoing monitoring of identified past trauma for 2 of 2 residents reviewed for Trauma Informed Care, of a total sample of 55 residents, (#25, #84).

Inspectors wroteBased on interview and record review, the facility failed to follow their grievance process related to preferences for 2 of 2 resident reviewed for grievances, (#1, #3). Findings 1. A review of the medical record revealed that resident # 3 was admitted to the facility on [DATE] with diagnoses that included cerebral palsy, major depressive disorder, unspecified psychosis and schizoaffective disorder. According to the Annual assessment of the Minimum Data Set with the assessment reference date of 9/30/25, the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which means he was cognitively intact, and was dependent on staff for hygiene care. On 10/8/25 at 10:06 AM, resident # 3 who was selected from the facility's grievance log was observed being wheeled into the shower room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections by failing to appropriately implement enhanced barrier precautions (EBP) during high-contact care activity for 1 of 6 residents (#5) requiring EBP on the Specialized Subacute Unit (SSU). The facility had a total of 20 residents who required EBP in a census of 154 residents. The facility capacity is 167 beds. On 10/08/25 at approximately 10:50 AM the light above the door to resident #5's was illuminated to indicate the resident was calling for assistance. Certified nursing assistant (CNA)- A was observed to obtain and don a mask from a caddy (container) hanging on the door across the hallway and she entered the room. [...]

Inspectors wroteBased on interview and record review, the facility failed to respond to grievances identified by resident council.

Inspectors wroteBased on interview and record review, the facility failed to provide the appropriate notices of financial liability for 2 of 3 resident reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification, out of a total sample of 63 residents, (#53 and #96).

Inspectors wroteBased on interview, and record review, the facility failed to notify the State Long Term Care Ombudsman in writing, by phone, or in person for a facility-initiated emergency transfer/discharge for 2 of 2 residents reviewed for [NAME] Act and 1 of 3 residents reviewed for hospitalization out of a total sample of 63 residents, (#561, #562 and #626).

Inspectors wroteBased on interview and record review, the facility failed to revise care plans to reflect current transfer status for 1 of 4 residents reviewed for accidents, (#1); accurate oxygen administration orders for 2 of 4 residents reviewed for respiratory care, (#56 and #57); failed to provide the opportunity to participate in review and revision of the plan of care for 1 of 2 residents reviewed for Care Planning, (#154); and failed to updated code status for 1 of 5 residents reviewed for Advance Directives, (#148), out of a total sample of 63 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dishes were rinsed at the appropriate temperature and with the proper level of sanitizer with regard to the dish machine's data plate and manufacturer's instructions and failed to maintain equipment in a safe condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program developed and implemented timely and appropriate plans of action to prevent repeat deficient practices related to respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adhere to proper infection control practices for cleaning of a glucometer to prevent the potential transmission of bloodborne pathogens for 1 of 2 residents tested for blood glucose levels, (#75), out of a total sample of 63 residents; and failed to ensure staff used proper hand hygiene during meal service with the potential to spread infection to residents on the [NAME] Wing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the right to make choices about significant aspects of activities of daily living related to the preferred method and frequency of baths for 2 of 5 residents reviewed for choices, out of a total sample of 63 residents, (#624 & #617).

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents wishes for a Do Not Resuscitate Order (DNRO) were honored for 1 of 2 residents, (#6), and failed to ensure residents had the capacity to make health decisions and sign for a DNRO for 1 of 2 residents reviewed for Advanced Directives, from a total sample of 63 residents, (#107).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected transfer status, (#1), and vision status, (#15), at the time of the assessments, for 2 of 63 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to refer residents with a newly evident mental disorder for Level II Preadmission Screening and Resident Review (PASARR) evaluation and determination for 2 of 6 residents reviewed for PASARR, out of a total sample of 63 residents, (#37 and #83).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policies and procedures and adhere to professional standards related to wound care and treatment for 1 of 5 residents reviewed for non-pressure skin conditions, out of a total sample of 63 residents, (#47).

Inspectors wroteBased on observation, interview, and record review, the facility failed to arrange services in a timely manner to ensure access to appropriate prescription glasses, (#15); and failed to provide glasses to maintain vision abilities, (#154), for 2 of 6 residents reviewed for Vision/Hearing out of a total sample of 63 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy was administered according to physician orders for 2 of 4 residents reviewed for respiratory care, out of a total sample of 63 residents, (#56 and #57).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and secure storage of medication to prevent access by unauthorized persons for 1 of 2 medication carts on the East Wing (400 hall).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide follow up dental services for 1 of 2 residents reviewed for Dental out of a total sample of 63 residents, (#154).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure required built up utensils and weighted cup were provided for 1 of 5 residents reviewed for nutrition of a total sample of 63 residents, (#41).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain smoking pole ashtrays to promote a safe environment in the designated smoking area; and failed to ensure hot water was available in two of three shower stalls in the [NAME] Wing shower room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected Range of Motion (ROM) for 2 of 2 residents reviewed for ROM (#258, #27) failed to accurately assess bowel continence for 1 of 1 resident (#61), failed to identify discharge status for 1 of 1 resident reviewed for discharge, (#1), failed to accurately assess dental status for 2 of 3 residents reviewed for dental, (#32, #27) and failed to accurately assess active diagnoses for 1 of 5 residents, (#27) out of a total sample of 65 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for splinting to prevent worsening of contractures for 4 of 5 residents reviewed for mobility of a total sample of 65 residents, (#27, #46, #74, and #137).

Inspectors wroteBased on interview and record review, the facility failed to complete a Level II Preadmission Screening and Resident Review (PASARR) to ensure appropriate placement and evaluation for specialized services for 1 of 1 resident reviewed for Level II PASARR, of a total sample of 65 residents, (#62).

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan to address necessary care and services for tracheostomy, oxygen, suctioning, feeding tube, activities of daily living, and pain management for 1 of 9 newly admitted residents, (#111); and failed to ensure the baseline care plan summaries were reviewed with the resident or resident representative within 48 hours for 3 of 9 newly admitted residents, (#111, #303, #258), out of a total sample of 65 residents.

Inspectors wroteBased on interview and record review, the facility failed to develop comprehensive care plans related to oxygen use for 1 of 4 residents reviewed for respiratory care, (#138).

Inspectors wroteBased on interview and record review the facility failed to develop comprehensive care plans within 7 days of completion of the comprehensive Minimum Data Set (MDS) assessment for 1 of 1 resident reviewed for catheter (#61) and for 1 of 5 residents reviewed for participation in care planning (#149), of a total sample of 65 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to schedule follow-up care with an orthopedic physician in a timely manner for 1 of 1 resident with a right wrist /hand fracture and right-hand cast, of a total sample of 65 residents, (#58).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide dressing changes for seven days for a midline intravenous (IV) catheter according to current professional standards of practice for 1 of 2 residents with IV catheters of a total sample of 65 residents, (#260).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen (O2) therapy was administered as per physician's orders for 1 of 3 residents reviewed for O2, of a total sample of 65 residents, (#62).

Inspectors wroteBased on interview and record review, the facility failed to ensure 10 of 12 required monthly drug regimen reviews were completed for 1 of 5 residents reviewed for Unnecessary Medications, Psychotropic Medications and Medication Regimen Review, out of a total sample of 65 residents, (#2).