Nursing & Rehabilitation Center of Melbourne

In the surveyor’s words

From the most serious findings on record at Nursing & Rehabilitation Center of Melbourne, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 24, 2021

  Based on observation, interview and record review, the facility failed to provide adequate supervision and determine appropriate safety interventions based on a thorough elopement risk evaluation, and failed to maintain a secure environment by implementing front desk procedures to ensure vulnerable residents did not exit the facility without supervision, for 1 of 11 residents at risk for elopement, (#1). These failures contributed to the elopement of resident #1 and placed him at risk for serious injury/impairment/death. […]

• Actual harm, isolatedF689May 24, 2022

  Based on observation, interview and record review, the facility failed to provide adequate supervision and assistive device for hot fluids during dining for 1 of 3 sampled residents which resulted in actual harm, (#1). Findings: Review of resident #1's medical record noted she was admitted to the facility on [DATE] with diagnoses of [CONDITION(S)], dementia, [CONDITION(S)] disorder, dysphagia, cognitive communication deficit and mixed receptive-expressive language disorder. Review of resident #1's admission Minimum Data Set assessment dated [DATE] showed her cognitive status was not able to be assessed due to inattention that fluctuated and continual disorganized thinking. […]

• No harm, potential for more than minimal, widespreadF880Nov 20, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF559Aug 12, 2026

  Based on observation, interview, and record review, the facility failed to provide written notice, including the reason for the change, prior to changing residents' room for 4 of 4 residents reviewed for room changes, out of a total sample of 14 residents, (#1, #3, #5, and #6).Findings: 1.Review of resident #1's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 6/08/26. Her diagnoses included stage 4 pressure ulcer of the sacral region, chronic obstructive pulmonary disease, type 2 diabetes, difficulty walking, lack of coordination, and need for assistance with personal care. […]

• No harm, potential for more than minimal, patternF585Aug 12, 2026

  Based on observation, interview, and record review, the facility failed to follow its grievance process related to a resident's room change request and concerns regarding call light response voiced during Resident Council meetings, for 2 out of 10 residents reviewed for grievances, (#1 and #4), and the Resident Council, out of a total sample of 14 residents. Findings: 1.Review of resident #1's medical record revealed she was originally admitted to the facility on [DATE] and readmitted from an acute care hospital on 6/08/26. Her diagnoses included stage 4 pressure ulcer of sacral region, chronic obstructive pulmonary disease, type 2 diabetes, difficulty walking, lack of coordination, and need for assistance with personal care. […]