Cycle 1
Health 2025-03-06 · Fire 2025-03-06
10 health deficiencies
Top issue: Resident Rights (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Melbourne, FL
Melbourne Healthcare And Rehabilitation Center
1-star overall rating with 1-star inspections with $59,140 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1415 S Hickory St, Melbourne, FL
(321) 723-1321
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
138
Certified beds
Average residents
126
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelsior Care Group
Operator or chain grouping
Approved since
1969-05-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
33 facilities
Chain averages 3 overall / 2 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.75
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.51
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.14
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.40
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.24
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.85
CMS adjusted RN staffing hours
Adjusted total hours
3.86
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,762
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.79
Composite VBP score used to determine payment impact.
Payment multiplier
0.9867
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
3.06
Performance 6.92% · Measure score 3.06 · Achievement 3.06 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
3.64
Performance 48.82% · Measure score 3.64 · Achievement 3.64 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.84
Baseline 3.96 hours · Performance 3.89 hours · Measure score 2.84 · Achievement 2.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.09% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 15% · Lower 95% interval 7.97% |
| Discharge to community | 41.02% |
50.57%
9.5 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 29.41% · Lower 95% interval 29.44% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 97 · Denominator 97 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 97 |
| Discharge self-care score | 62.07% |
53.69%
8.4 pts better
|
Numerator 36 · Denominator 58 |
| Discharge mobility score | 53.45% |
50.94%
2.5 pts better
|
Numerator 31 · Denominator 58 |
| Pressure ulcers or injuries, new or worsened | 4.12% |
2.29%
1.8 pts worse
|
Numerator 4 · Denominator 97 · Adjusted rate 4.12% |
| Healthcare-associated infections requiring hospitalization | 6.92% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 6.67% · Lower 95% interval 3.35% |
| Staff COVID-19 vaccination coverage | 6.09% |
8.2%
2.1 pts worse
|
Numerator 14 · Denominator 230 |
| Staff flu vaccination coverage | 9.48% |
42%
32.5 pts worse
|
Numerator 20 · Denominator 211 |
| Discharge function score | 53.45% |
56.45%
3 pts worse
|
Numerator 31 · Denominator 58 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 48 · Denominator 48 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.98% |
25.2%
8.2 pts worse
|
Numerator 9 · Denominator 53 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
2.1
1.6 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.6 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.2
0.4 pts worse
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.5 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
97.8%
2 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
99.2%
0.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
2.6%
1.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.0% · Q4 2.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
3.7%
3.2 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 15.3% |
5.9%
9.4 pts worse
|
5.4%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.7% · Q2 18.0% · Q3 11.1% · Q4 7.4% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.2% |
15.7%
5.5 pts better
|
19.6%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 10.9% · Q3 9.7% · Q4 10.4% · 4Q avg 10.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.8% |
9.8%
1 pts better
|
16.7%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.9% · Q3 8.5% · Q4 14.3% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.4% |
11.7%
3.3 pts better
|
16.3%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 12.5% · Q3 0.0% · Q4 2.5% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
9.8%
3.9 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 4.9% · Q3 8.3% · Q4 3.5% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 5.0% |
12.5%
7.5 pts better
|
19.8%
14.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.4% · Q3 4.5% · Q4 4.4% · 4Q avg 5.0% |
| Percentage of long-stay residents with pressure ulcers | 7.6% |
5.1%
2.5 pts worse
|
5.1%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 7.5% · Q3 9.7% · Q4 9.2% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.7% |
94.3%
4.4 pts better
|
81.7%
17 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 98.9% · Q3 98.7% · Q4 98.1% · 4Q avg 98.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.2% |
9.3%
7.9 pts worse
|
12.0%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 19.4% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
94.7%
3.1 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 37.7% |
26.2%
11.5 pts worse
|
23.9%
13.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 37.7% · Observed 38.9% · Expected 24.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-22 · Fire 2023-06-22
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2021-08-05 · Fire 2021-08-05
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-06
F · Potential for more than minimal harm
2023-06-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-07-20
F · Potential for more than minimal harm
2021-08-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2021-09-04
F · Potential for more than minimal harm
2021-08-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-09-04
F · Potential for more than minimal harm
2021-08-05
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2021-09-04
F · Potential for more than minimal harm
2021-08-05
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-09-04
D · Potential for more than minimal harm
2021-08-05
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2021-09-04
D · Potential for more than minimal harm
2021-08-05
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-09-04
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-06
E · Potential for more than minimal harm
2025-03-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-03-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-04-06
D · Potential for more than minimal harm
2024-12-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-12-04
J · Immediate jeopardy
2024-11-22
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-23
J · Immediate jeopardy
2024-11-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-11-23
E · Potential for more than minimal harm
2024-11-22
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-11-23
D · Potential for more than minimal harm
2023-06-22
F578 · Resident Rights Deficiencies
Health
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.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-20
G · Actual harm
2023-05-05
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-06-22
E · Potential for more than minimal harm
2023-03-30
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-04-30
E · Potential for more than minimal harm
2021-08-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-09-04
Penalties and ownership
What sits behind the stars
$40,132
2024-11-22
Fine
Fine · fine $40,132
Fine
$8,648
2023-05-05
Fine
Fine · fine $8,648
Fine
$10,360
2023-05-05
Fine
Fine · fine $10,360
Fine
Ownership
Carnegie Gardens Operating Investments LLC
5% Or Greater Direct Ownership Interest · Organization
Bdcc Consutking Group LLC
5% Or Greater Indirect Ownership Interest · Organization
David, Rochel
5% Or Greater Indirect Ownership Interest · Individual
Fdz Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Friedman, Leah
5% Or Greater Indirect Ownership Interest · Individual
Jz Consulting LLC
5% Or Greater Indirect Ownership Interest · Organization
Powers, Brian
5% Or Greater Indirect Ownership Interest · Individual
Rubenstein, David
5% Or Greater Indirect Ownership Interest · Individual
Rubiweb Florida Services Group Usa LLC
5% Or Greater Indirect Ownership Interest · Organization
Weber, Aron
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Charles
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
5% Or Greater Indirect Ownership Interest · Individual
Zahler, Jacob
Operational/Managerial Control · Individual
Zahler, Jacob
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Life Care Center Of Melbourne
Melbourne, FL
5-star overall rating with 4-star inspections with 2 recent health deficiencies
#2
Avante At Melbourne Inc
Melbourne, FL
1-star overall rating with 1-star inspections with abuse icon flag with $87,952 in total fines with 16 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Melbourne Terrace Rehabilitation Center
Melbourne, FL
3-star overall rating with 3-star inspections with $15,646 in total fines with 6 recent health deficiencies
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