Deficiency Records for Nursing and Rehabilitation Center of Melbourne
Updated as of March 01, 2024
A list of the most recent deficiencies for Nursing and Rehabilitation Center of Melbourne. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-31 | 2024-01-09 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-11-02 | 2023-11-30 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-02 | 2023-11-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-11-02 | 2023-11-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-11-02 | 2023-11-30 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-02 | 2023-11-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-02 | 2023-11-30 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-02 | 2023-11-30 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-02 | 2023-11-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-02 | 2023-11-30 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-11-02 | 2023-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-02 | 2023-11-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-11-02 | 2023-11-30 | N |
| Provide or obtain dental services for each resident. | Health | 2023-11-02 | 2023-11-30 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2023-11-02 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-02 | 2023-11-30 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-02 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-02 | 2023-11-30 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-31 | 2023-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-31 | 2023-11-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-24 | 2023-02-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-24 | 2022-06-24 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-01-31 | 2022-03-04 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-02-03 | 2022-03-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-03 | 2022-03-03 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-02-03 | 2022-03-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-03 | 2022-03-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-03 | 2022-03-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-02-03 | 2022-03-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-03 | 2022-03-03 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-02-03 | 2022-03-03 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2022-02-03 | 2022-03-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-02-03 | 2022-03-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-02-03 | 2022-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-24 | 2021-05-14 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-10-08 | 2020-10-31 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-10-08 | 2020-10-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-10-08 | 2020-10-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-08 | 2020-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-08 | 2020-10-31 | N |
| Post nurse staffing information every day. | Health | 2020-10-08 | 2020-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-10-08 | 2020-10-31 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-10-08 | 2020-10-31 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-10-06 | 2020-10-31 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-10-06 | 2020-10-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-06 | 2020-10-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-10-06 | 2020-10-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2020-10-06 | 2020-10-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-06 | 2020-10-31 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2020-10-06 | 2020-10-31 | N |
