Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Nursing & Rehabilitation Center Of Melbourne during CMS and state inspections, most recent first.
A resident admitted with a complicated UTI, an indwelling Foley catheter, moderate cognitive impairment, and dependence in ADLs did not have any physician orders or care plan entries for catheter care or monitoring, despite documentation in an admission note and on the MDS that a catheter was present. The admitting RN incorrectly recorded that no catheter was present on the admission assessment, resulting in no catheter care orders populating the TAR. Throughout the stay, staff, including the unit manager and DON, later acknowledged the catheter was in place but could not locate any catheter care or monitoring orders in the record, even though facility policy required catheter care every shift and as needed.
The facility did not follow its grievance process for two residents who reported concerns about care, including delays in assistance and denial of a requested shower. In both cases, grievances were either not logged or not fully documented, lacked required signatures and follow-up, and were not resolved according to policy. Facility staff acknowledged incomplete investigation and failure to keep residents informed, resulting in noncompliance with grievance procedures.
Staff failed to follow Enhanced Barrier Precautions (EBP) for a resident with a suprapubic catheter and MDRO history during high-contact care activities, such as bathing, dressing, and transferring. Despite posted signage and facility policy requiring both gloves and gowns, staff only wore masks and gloves, and were unaware of the need for gowns. The RN and Infection Preventionist also demonstrated gaps in knowledge and monitoring of EBP adherence, and PPE supplies were not available at the point of care.
Failure to Implement Orders and Monitoring for Indwelling Urinary Catheter
Penalty
Summary
The deficiency involves the facility’s failure to ensure proper orders, care planning, and monitoring for an indwelling urinary catheter for one resident. The resident, an [AGE]-year-old female admitted from an acute care hospital with anemia, elevated white blood cell count, and a complicated UTI, had a documented Foley catheter on admission and throughout her stay. The Five-day MDS showed the resident had an indwelling urinary catheter, moderate cognitive impairment, dependence in ADLs, and was receiving high-risk medications including IV antibiotics for UTI. However, the physician Order Summary Report contained no orders or directions for monitoring or caring for the Foley catheter, and the Care Plan Report did not address the presence, care, or monitoring of the catheter, the UTI, or IV antibiotics. The nurse who completed the admission assessment documented the catheter in the admission note but incorrectly marked the admission data collection tool as negative for an indwelling catheter, and no catheter care orders were entered to generate tasks on the TAR. Review of the TAR for the month showed no orders or directions for catheter care or monitoring. Multiple staff, including the admitting RN, the Subacute Unit Manager, and the DON, later confirmed that the resident had a catheter during the stay and acknowledged that catheter orders were missed and not entered into the record. The facility’s written catheter care policy required that residents with indwelling catheters receive appropriate catheter care every shift and as needed, but this was not implemented for this resident due to the lack of documented orders and monitoring directives.
Failure to Follow Grievance Process and Incomplete Documentation
Penalty
Summary
The facility failed to follow its established grievance process for two residents who voiced concerns regarding their care. One resident, with diagnoses including cerebral palsy, major depressive disorder, unspecified psychosis, and schizoaffective disorder, was cognitively intact and dependent on staff for hygiene. This resident filed a grievance about prolonged wait times to get out of bed and staff turning off the call light. Although the Social Services Director (SSD) acknowledged the complaint and stated that staff had been educated, the grievance form was incomplete, unsigned, and did not document resolution, contrary to facility policy requiring prompt resolution and proper documentation. Another resident, also cognitively intact and with multiple medical conditions, reported being denied a shower on a non-scheduled night and subsequently being left soiled until the following morning. The grievance was not entered into the facility's grievance log, and the documentation was incomplete, lacking signatures, dates, and statements from all involved staff. The Social Service Assistant (SSA) and SSD confirmed the grievance was not logged, and the Director of Nursing (DON) admitted to incomplete staff interviews and missing documentation. The Nursing Home Administrator (NHA) acknowledged that the grievance was not properly reviewed or discussed by the management team. Facility policy requires that all grievances be logged, investigated, and resolved promptly, with residents kept informed of progress and provided with a written decision. In both cases, the facility did not adhere to its own grievance procedures, resulting in incomplete documentation, lack of timely resolution, and failure to keep residents appropriately apprised of the status of their grievances.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program by not properly implementing Enhanced Barrier Precautions (EBP) for a resident requiring such measures. During an observation, a certified nursing assistant (CNA) responded to a call light for a resident with a suprapubic urinary catheter and a history of multidrug-resistant organism (MDRO) colonization. The CNA donned only a mask and entered the room, later joined by another CNA and a private sitter, both of whom wore masks and gloves but not gowns. These staff members had just completed bathing and dressing the resident and were preparing to transfer him using a mechanical lift, all of which are high-contact care activities requiring both gloves and gowns per EBP protocols. When questioned, the staff indicated they believed gowns were not necessary for this type of care, despite signage on the door and facility policy indicating otherwise. Further interviews revealed that the registered nurse (RN) assigned to the unit also misunderstood the requirements for EBP, stating that gowns were only needed for airborne precautions and not for residents with MDROs or indwelling catheters. The Infection Preventionist (IP), who also served as Assistant Director of Nursing and Staff Development, confirmed that staff had been educated on EBP but acknowledged that there was no ongoing surveillance process to monitor adherence to PPE protocols. Additionally, the list of residents requiring EBP was found to be inaccurate, missing two residents who should have been included. Record review for the affected resident showed active orders for EBP due to the presence of a suprapubic catheter and a history of MDRO, with care plans reflecting the need for assistance with activities of daily living. Facility policy required gowns and gloves to be available near or outside the resident's room and mandated staff compliance with EBP during high-contact care activities. However, during the survey, PPE supplies were not observed at the point of care, and staff failed to follow established protocols, resulting in a breakdown of infection control practices.
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Nursing homes near Melbourne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Indian River Center | 1.9 mi | — | 0 | 0 |
| West Melbourne Health & Rehabilitation Center | 3.2 mi | — | 14 | 0 |
| Life Care Center Of Melbourne | 4.6 mi | — | 2 | 0 |
| Melbourne Healthcare And Rehabilitation Center | 4.6 mi | — | 0 | 0 |
| Avante At Melbourne Inc | 4.8 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.