21 health deficiencies
Top issue: Resident Rights (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Merritt Island, FL
2-star overall rating with 1-star inspections with abuse icon flag with $128,889 in total fines with 21 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
125 Alma Blvd, Merritt Island, FL
(321) 453-0202
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
120
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Excelsior Care Group
Operator or chain grouping
Approved since
1978-07-01
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
RN hours / resident day
0.60
Registered nurse staffing · state 0.73 · national 0.68
LPN hours / resident day
0.74
Licensed practical nurse staffing · state 0.79 · national 0.87
Aide hours / resident day
2.12
Nurse aide staffing · state 2.34 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.86 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.52 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.53 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
4.04
CMS adjusted total nurse staffing hours
Case-mix index
1.17
Higher values indicate more complex resident acuity
RN turnover
45%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 42% · national 46%
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 11.76% · Lower 95% interval 7.35% |
| Discharge to community | 44.88% |
50.57%
5.7 pts worse
|
No Different than the National Rate · Eligible stays 27 · Observed rate 29.63% · Lower 95% interval 31.94% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 77 · Denominator 77 |
| Falls with major injury | 1.3% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 77 |
| Discharge self-care score | 59.02% |
53.69%
5.3 pts better
|
Numerator 36 · Denominator 61 |
| Discharge mobility score | 52.46% |
50.94%
1.5 pts better
|
Numerator 32 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 6.49% |
2.29%
4.2 pts worse
|
Numerator 5 · Denominator 77 · Adjusted rate 6.12% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 21 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 79.73% |
42%
37.7 pts better
|
Numerator 118 · Denominator 148 |
| Discharge function score | 63.93% |
56.45%
7.5 pts better
|
Numerator 39 · Denominator 61 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 28 · Denominator 28 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 41 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.2
0.3 pts worse
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
97.8%
1.4 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 97.8% · 4Q avg 99.2% |
| 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 | 3.9% |
2.6%
1.3 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.4% · Q3 4.6% · Q4 2.2% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
3.7%
2.5 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.6% · Q4 1.2% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 10.5% |
5.9%
4.6 pts worse
|
5.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 13.7% · Q3 9.4% · Q4 11.4% · 4Q avg 10.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.6% |
15.7%
1.9 pts worse
|
19.6%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.2% · Q2 15.1% · Q3 13.8% · Q4 17.1% · 4Q avg 17.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.1% |
9.8%
7.3 pts worse
|
16.7%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 17.6% · Q3 14.9% · Q4 18.4% · 4Q avg 17.1% · 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 | 6.5% |
11.7%
5.2 pts better
|
16.3%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 9.5% · Q3 6.3% · Q4 0.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 3.5% |
9.8%
6.3 pts better
|
14.9%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 1.4% · Q3 3.1% · Q4 0.0% · 4Q avg 3.5% · 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 | 0.6% |
0.8%
0.2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.2% |
12.5%
8.3 pts better
|
19.8%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.6% · Q2 3.5% · Q3 3.4% · Q4 1.1% · 4Q avg 4.2% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
5.1%
0.6 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 5.7% · Q3 6.4% · Q4 4.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.9% |
94.3%
0.4 pts worse
|
81.7%
12.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.7% · Q3 94.1% · Q4 86.1% · 4Q avg 93.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
9.3%
6.8 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 18.2% · Expected 12.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.5% · Q3 0.0% · Q4 1.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.7%
5.3 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 11.5% |
26.2%
14.7 pts better
|
23.9%
12.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 12.1% · Expected 25.2% · Used in QM five-star |
Survey summary
Top issue: Resident Rights (6 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Top issue: Quality of Life and Care (3 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Resident Rights (5 deficiencies)
4 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-17
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-06-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-26
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-06-26
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-06-26
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-26
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2023-06-26
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-06-26
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-26
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-07-17
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2021-07-17
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-07-17
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2021-07-17
Inspection history
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-29
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2025-08-29
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-08-29
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-08-29
Health
Respond appropriately to all alleged violations.
Corrected 2025-08-29
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-08-29
Health
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Corrected 2025-02-17
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 2025-02-17
Health
Dispose of garbage and refuse properly.
Corrected 2025-02-17
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-02-17
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-17
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-02-17
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-17
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-02-17
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-02-17
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-02-17
Health
Provide activities to meet all resident's needs.
Corrected 2025-02-17
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-02-17
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-02-17
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 2025-02-17
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 2025-02-17
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-06-16
Health
Respond appropriately to all alleged violations.
Corrected 2024-04-28
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-03-13
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 2023-06-26
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-26
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-26
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-26
Health
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
Corrected 2023-06-26
Health
Keep all essential equipment working safely.
Corrected 2023-06-26
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-06-26
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-06-26
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-06-26
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-06-26
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-26
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-06-26
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-07-17
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 2021-07-17
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2021-07-17
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2021-07-17
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-07-17
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-17
Penalties and ownership
Fine · fine $117,940
Fine
Fine · fine $7,409
Fine
Fine · fine $1,764
Fine
Fine · fine $1,776
Fine
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
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