Melbourne Healthcare and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Melbourne Healthcare and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Nov 22, 2024

  Based 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 . […]

• Immediate jeopardy, isolatedF689Nov 22, 2024

  Based 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 . […]

• Immediate jeopardy, isolatedF578Feb 19, 2021

  Based on interview and record review, the facility failed to honor advance directives for a Do Not Resuscitate Order (DNRO) for 1 of 7 residents reviewed for advance directives, (#1). This failure contributed to resident #1 receiving cardiopulmonary resuscitation (CPR) despite her explicit wish for a natural, dignified death and placed her at risk for serious injury/impairment/prolonged death. While resident #1 suffered resuscitation attempts including chest compressions for about 30 minutes, there was high likelihood she could have experienced pain, broken bones, organ damage and a prolonged dying process on mechanical life support. On [DATE] at 6 AM, resident #1 was found with shallow respirations and no pulse. Her assigned nurse, Registered Nurse (RN) A, immediately began CPR. […]

• Actual harm, isolatedF622May 5, 2023

  Based on interview, and record review, the facility failed to allow a resident to remain in the facility, failed to provide rationale as to why the resident's care needs could not be met at the facility and failed to document attempts at meeting those needs before transfer for 1 of 3 residents reviewed for transfers of a total sample of 5 residents, (#1). Findings: Resident #1 was admitted to the facility on the evening of 4/04/23 from an acute care hospital with diagnoses that included heart failure, chronic lung disease, anxiety disorder, left great toe amputation and alcohol abuse. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2025

  Based 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. Findings: 1. On 3/03/25 at 10:00 AM, during the initial kitchen tour with the Assistant Dietary Manager I, observations in the walk-in found there were four, one-third steamtable pans of leftover food items including mechanical soft pork dated 3/1 and use by 3/07/25, sweet potatoes dated 3/2 and use by 3/08/25, corn dated 3/1 use by 3/07/25, and mashed potatoes dated 3/2 use by 3/08/25. […]