West Melbourne Health & Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF684Apr 12, 2023

  Based on interview, and record review, the facility failed to ensure effective communication and collaboration between members of the interdisciplinary team to provide necessary care and services to attain the highest practicable well-being and prevent complications related to a urinary tract infection (UTI) for 1 of 4 residents reviewed for UTIs, of a total sample of 11 residents, (#1). The facility's failure to follow the physician's orders and treat a change in condition resulted in actual harm. Findings: Review of resident #1's medical record revealed he was originally admitted to the facility on [DATE]. He was discharged to the hospital on 8/09/22 and readmitted on [DATE]. His diagnoses included retention of urine, chronic prostatitis, benign prostatic hyperplasia, and stroke. […]

• No harm, potential for more than minimal, widespreadF814Mar 16, 2022

  Based on observation and interview, the facility failed to ensure the garbage storage area was maintained in clean and sanitary condition. Finding: During the initial kitchen inspection on 3/13/22, the garbage storage area was observed at 11:10 AM. There was a trash compactor and dumpster for recycling with one of the doors open. Debris was scattered on the ground including white/clear gloves, milk cartons and other refuse. Cook Z was in the area and said the dumpster doors should be closed at all times. He said the gloves were used by nursing staff as the kitchen staff used black gloves. […]

• No harm, potential for more than minimal, widespreadF867Mar 16, 2022

  Based 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. Findings: Cross Reference F584, F636, F638 and F640 Review of the facility's survey history revealed repeat deficiencies and systemic concerns with the resident's physical environment over the past four years, and for the current recertification survey. Past deficiencies noted failures in maintaining comfortable resident rooms, resident equipment and furniture. […]

• No harm, potential for more than minimal, patternF565Dec 4, 2025

  Based 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).Findings: During Resident Council meeting on 12/02/25 at 10:34 AM, members of Resident Council verified they met monthly. The members stated several grievances had been voiced regarding nurse and aide staffing, staff customer service and dietary issues. The residents in attendance agreed the same concerns were voiced month after month without a resolution from the facility. The group expressed no one ever responded to the grievances and informed them of what was done. […]

• No harm, potential for more than minimal, patternF812Dec 4, 2025

  Based 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.Findings:On 12/01/25 at 10:10 AM, the initial kitchen tour inspection was conducted with the Kitchen Manager. She stated she had been in the position for two years but had been a Certified Nursing Assistant prior to her current position. Initial observation found the floor unclean, as evidenced by stuck on food under the tables and equipment. The Kitchen Manager said the floors were cleaned every night prior to closing the kitchen but once per month the Maintenance Department power washed the floors. She was unsure when maintenance had last done the floors. […]