West Melbourne Health & Rehabilitation Center

Inspectors wroteBased on interview, and record review, the facility failed to respond in writing to repeated grievances identified by resident council over a six-month period, (June to November 2025).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the overall cleanliness of the kitchen and ensure that food was stored and distributed in a sanitary manner.

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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote dignity during dining for 1 of 2 residents reviewed for dignity, of a total sample of 49 residents, (#20).

Inspectors wroteBased on interview, and record review, the facility failed to follow generally accepted accounting principles in the management of resident personal funds for 1 of 2 residents reviewed for personal funds, of a total sample of 49 residents, (#13).

Inspectors wroteBased on interview, and record review, the facility failed to refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility, for 1 of 1 resident reviewed for discharge, of a total sample of 49 residents, (#151).

Inspectors wroteBased on observation, interview, and record review, 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 1 of 3 units, (B-Wing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the grievance process by not making a prompt effort to resolve a grievance and not keeping the resident apprised of the progress toward resolution for 1 of 3 residents reviewed for personal property, of a total sample of 49 residents, (#20).

Inspectors wroteBased on interview, and record review, the facility failed to develop a comprehensive person-centered care plan for a resident with antipsychotic medications for 1 of 5 residents reviewed for high-risk medications, of a total of 49 residents, (#116); the facility failed to develop an individualized care plan to include paranoid schizophrenia for 1 of 5 residents reviewed for Pre-admission Screening and Resident Review (PASARR), (#103),of a total sample of 49 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper and timely assistance with Activities of Daily Living (ADLs) to maintain cleanliness and dignity for 2 of 3 residents reviewed for ADLs, of a total sample of 49 residents, (#20 and #143).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the recommended Restorative Nurse Program (RNP) to provide mobility and Range of Motion (ROM) services to improve or maintain functional ability for 1 of 2 residents reviewed for rehabilitation and restorative services, out of a total sample of 49 residents, (#13).

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain physician orders for respiratory treatments for 1 of 2 residents reviewed for respiratory care, of a total sample of 49 residents, (#33).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who experienced trauma received trauma-informed care for 1 of 2 residents reviewed for mood/behavior, of a total sample of 49 residents, (#9).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete medical records were readily accessible, and not restricted to access for 16 of 16 total sampled residents, (#1, #2, #3, #4, #5, #6, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25); and failed to ensure hard copy medical records were safeguarded for all residents.

Inspectors wroteBased on interview, and record review, the facility failed to complete dietary assessment within recommended timeframes for 2 of 2 residents and failed to obtain preferences and allergies pertaining to lactose intolerance for 1 resident of a total sample of 16 residents, (#20, #24).

Inspectors wroteBased on interview and record review, the facility failed to provide written Notification of Transfer or Discharge forms to the residents or their representative for 1 of 1 resident reviewed for hospitalization, out of a total sample of 52 residents, (#5).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dishes were washed at the appropriate temperature, with regard to the dish machine's data plate and manufacturer's instructions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain proper infection control practices to prevent contamination during tracheostomy care for 1 of 4 residents reviewed for respiratory care, (#40) and failed to ensure the appropriate personal protective equipment (PPE) was donned prior to entry to transmission-based precaution rooms to prevent the potential for cross contamination for 2 of 2 residents reviewed for transmission-based precautions, (#109, #199) of a total sample of 52 residents.

Inspectors wroteBased on interview, and record review, the facility failed to develop a baseline care plan within 48 hours of admission for 1 of 1 resident reviewed for pain management of a total sample of 52 residents, (#199).

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were involved in developing the comprehensive person-centered plan of care for 1 of 3 residents reviewed for participation in care plan, of a total sample of 52 residents, (#52). Findings Resident #52, a [AGE] year-old female was admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included chronic systolic (congestive) heart failure, diabetes type II, mild intermittent asthma, other chronic pain, and shortness of breath. Review of the resident's annual Minimum Data Set (MDS) assessment, with Assessment Reference Date of 9/20/23 revealed the resident's cognition was intact, with a Brief Interview for Mental Status score of 15 out of 15. On 12/11/23 at 4:04 PM, resident #52 stated she did not get invited to her care plan meetings. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide fingernail care for a dependent resident, for 1 of 3 residents reviewed for Activities of Daily Living (ADL) care of a total sample of 52 residents, (#7).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurses followed physician's Leave of Absence (LOA) orders and failed to provide necessary monitoring and supervision to mitigate the risk of serious injury for 1 of 7 residents reviewed for Accidents, of a total sample of 52 residents, (#77).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a Midline dressing was changed in accordance with professional standards to prevent the potential for infection for 1 of 1 resident reviewed for antibiotic use of a total sample of 52 residents, (#198).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards of practice pertaining to tracheostomy care and suctioning for 1 of 4 residents (#40), and failed to ensure Oxygen (O2) therapy was administered per physician's order for 1 of 2 residents reviewed for O2 therapy, (#52) of a total sample of 52 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff were competent to care for residents with tracheostomy for 1 of 4 residents reviewed for respiratory care of a total of 52 residents, (#40).

Inspectors wroteBased on observation and interview, the facility failed to ensure the garbage storage area was maintained in clean and sanitary condition.

Inspectors wroteBased on observation, interview and record, 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 physical environment and Minimum Data Set (MDS) assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean, comfortable and homelike environment in 7 resident rooms, (A-109, A-110, A-120, B-202, B-223, C-309, C-324), on 3 of 3 units, (A, B and C Wings).

Inspectors wroteBased on interview and record review, the facility failed to ensure Annual and Significant Change in Status Minimum Data Set (MDS) assessments were completed within 14 days of the assessment reference date (ARD) for 5 of 16 residents reviewed for Resident Assessment, of a total sample of 56 residents, ( #1, #2, #4, #7 & #12).

Inspectors wroteBased on interview and record review, the facility failed to ensure Quarterly Minimum Data Set (MDS) assessments were completed within 14 days of the assessment reference date (ARD) for 7 of 16 residents reviewed for Resident Assessment, of a total sample of 56 residents, ( #3, #6, #10, #11, #14, #16 & #40).

Inspectors wroteBased on observation, interview and record review, the facility failed to follow and serve therapeutic diets as per facility's menu and for 2 of 11 residents observed for dining/nutritional concerns, (#128 and #636).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident dignity during incontinence care for 1 of 5 residents reviewed for dignity of a total sample of 56 residents, (#107). Findings Review of resident #107's medical record documented he was admitted to the facility on [DATE] with diagnoses of stroke and Arteriosclerotic Heart Disease. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed he was cognitively intact, required extensive assistance with all Activities of Daily Living (ADLs), had impairment on one side of upper and lower extremity and was always incontinent of bowel and bladder. Review of the resident's plan of care revealed the resident was unable to perform self care, required total assistance with ADLs with intervention to provide privacy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS) assessments were transmitted to the Centers for Medicare and Medicaid Services (CMS) within 14 days of completion, for 1 of 16 residents reviewed for Resident Assessment, of a total sample of 56 residents, (#6).

Inspectors wroteBased on observation, interview, and record review, the facility failed to incorporate expressed choices for preferred activities into the plan of care, and failed to ensure access to a television provided by family to promote the highest practicable well-being for 1 of 2 residents reviewed for activities, of a total sample of 56 residents, (#8).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen was administered as ordered by the physician for 1 of 5 residents reviewed for respiratory care, of a total sample of 56 residents, (#8).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pain management was provided consistent with professional standards of practice for 1 of 2 sampled residents, of a total sample of 56 residents, (#637).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen concentrator's external filter was maintained in a clean and sanitary manner to promote oxygen flow for 1 of 5 residents reviewed for respiratory care of a total sample of 56 residents, (#132).