Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Space Coast Healthcare And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with type 1 DM and an insulin pump was admitted with hospital discharge orders for insulin and BG monitoring, but the admission orders and MAR omitted those critical orders. Nursing staff and the IDT reviewed the hospital paperwork yet did not identify the missing insulin and finger stick orders, and no BG checks were completed for eight days. The resident later developed severe hyperglycemia, was found on the floor, and required 911 transfer, ICU-level care, and IV insulin.
Nurses and nurse aides lacked the necessary competencies to provide care that maximizes each resident's well-being. Staff were not adequately prepared to meet the individualized needs of residents, resulting in care that did not support their highest practicable level of well-being.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action, resulting in a lack of systematic review and response to quality issues.
The facility failed to manage and provide access to residents' personal funds, affecting two residents. One resident, despite having a significant account balance, faced repeated denials when accessing funds for necessary purchases. Another resident discovered a negative balance in her account, which was withheld to cover the deficit without her consent. The facility's transition to a new company caused delays and cash shortages, violating their policy of providing cash within one day of request.
The facility failed to create a homelike dining environment for residents in the B Wing dining room. Observations revealed that tables lacked tablecloths, centerpieces, and decorations, and the room was silent without music. Meals were served on trays, which were not removed or arranged on the tables, and staff left the room after serving. A CNA and the Administrator acknowledged the lack of a homelike atmosphere.
The facility failed to dispose of waste properly due to a damaged dumpster with missing and warped lids, which was observed during a kitchen inspection. The dumpster, in disrepair for about two months, contained garbage bags with food items and adult briefs, with one bag torn open. The Certified Dietary Manager and Maintenance Director acknowledged the issue, but the Administrator was unaware until the survey. The facility continued using the dumpster despite its condition, violating the FDA's 2017 Food Code requirement for tight-fitting lids.
The facility's QAPI committee failed to sustain improvements, resulting in repeat deficiencies at F584, F585, F694, and F814. Despite monthly meetings and data reviews, insufficient auditing and oversight led to noncompliance. The Administrator acknowledged a system breakdown in sustaining improvements.
The facility failed to ensure proper infection control measures by not having correct signage and readily available PPE for residents on Enhanced Barrier Precautions (EBP). Observations showed incorrect or missing EBP signage and PPE stored away from resident rooms. Additionally, resident equipment was improperly stored, with unlabeled basins found on the bathroom floor, breaching infection control protocols.
Two residents with severe cognitive impairment experienced a lack of dignity during dining. One resident had to lick dessert from containers due to inappropriate utensils, while another waited 45 minutes for lunch due to kitchen delays and staff oversight. The DON acknowledged the need for timely meal service and staff presence.
Two residents were found self-administering medications without proper evaluation or physician orders. One resident used nasal spray, while another took Vitamin B-12 and had an empty Rosuvastatin container. Both had intact cognition, but their clinical records lacked necessary assessments and orders. An LPN confirmed the oversight, and the DON acknowledged the deficiency, which violated the facility's policy requiring interdisciplinary assessment and physician orders for self-administration.
A HIPAA violation occurred when a computer screen on a medication cart was left unlocked, exposing a resident's medical information to passersby. The ADON admitted to leaving the screen open after checking the resident's name, contrary to the facility's policy requiring staff to lock computers when not in use.
A resident reported a missing cell phone, but the facility failed to document the grievance or resolve the issue promptly. Despite informing staff, the grievance was not logged, and the resident had to buy a new phone, impacting her communication with family. The Social Services Director and Unit Manager were aware but did not follow the grievance process.
The facility failed to provide adequate grooming and hygiene care for three residents, resulting in deficiencies in their ADL care. A resident with severe cognitive impairment was observed with long, dirty nails, while another had long facial hair on her chin. A third resident, with moderately impaired cognition, had untrimmed nails with a dark substance underneath. Staff acknowledged the oversight, despite facility policies requiring regular grooming and hygiene maintenance.
The facility failed to provide an ongoing program of activities for three residents, who were observed without engaging in any activities despite their care plans indicating preferences for music, social activities, and outdoor time. The Activity Director's documentation did not reflect any actual activities being provided, highlighting a deficiency in meeting the residents' needs.
A resident with diabetes and glaucoma experienced a delay in receiving necessary eye care due to the facility's failure to follow up on multiple orders for a retinal consult. The resident's optometrist had noted bleeding behind the eye, requiring specialist attention, but the facility's scheduling process missed the orders due to incorrect entry as prescriber written instead of verbal or telephone orders. This led to a significant delay in treatment.
A facility failed to change a resident's IV dressing as scheduled, leading to a potential 10-day gap without a change. The resident, with a history of MRSA and a current wound infection, was receiving IV antibiotics. The MAR lacked documentation for a dressing change on a specific date, and the DON confirmed the oversight. The RNC identified an issue with the as-needed order setup, preventing proper documentation.
The facility failed to implement pharmacy recommendations and physician orders for three residents, leading to deficiencies in medication management. A resident had multiple unaddressed pharmacist recommendations, including dose reductions and medication discontinuations. Another resident's medication adjustments to reduce fall risk were not implemented, and a third resident's agreed-upon changes for Psyllium and insulin were not reflected in their orders. The DON acknowledged issues with the MRR process, including lack of rationale for physician disagreements.
A facility failed to limit a PRN order for Xanax to 14 days for a resident with schizophrenia, psychosis, dementia, depression, seizures, and chronic kidney disease. The order, dated without a stop date, was not re-evaluated as required. Interviews with staff revealed that PRN Xanax is typically prescribed for 14 days, and the facility's policy lacked a stop date protocol for PRN psychotropic medications.
A facility failed to prevent a mentally impaired resident from exiting unsupervised, despite being identified as an elopement risk. The resident left through a window with a broken latch and was found walking on a busy road without shoes. Staff failed to secure the window and did not increase supervision despite the resident's history and recent behavioral changes.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Implement Admission Insulin and Blood Glucose Orders
Penalty
Summary
The facility failed to implement and review physician admission orders for a newly admitted resident with type 1 diabetes mellitus and an insulin pump. The resident was admitted from an acute care hospital with diagnoses that included acute metabolic encephalopathy, diabetes mellitus, hyperglycemia, seizures, pneumonia, hypotension, dialysis dependence, and a history of blood clot. Hospital discharge documents sent with the resident listed continued insulin-related orders, including an insulin pump, Lantus, and Lispro, but the facility’s admission orders and MAR did not include insulin or blood glucose monitoring orders. Record review showed that the resident’s admission physician orders included other medications, but no orders for insulin or point-of-care blood glucose checks were entered. Nursing and provider interviews indicated staff expected insulin and finger stick orders to be present for a diabetic resident, especially one with an insulin pump, but the orders were not verified or transcribed into the EMR. The IDT reviewed the resident’s hospital records and admission orders, yet did not identify that the insulin and glucose monitoring components were missing. The resident’s chart also showed no finger stick blood glucose checks were completed for eight days after admission. During that period, the resident’s condition worsened. On the day she was found sitting on the floor in her room, two finger stick blood glucose readings registered as high, and she was sent by 911 EMS to the hospital. Hospital records documented diabetic hyperglycemia and ICU-level care with IV insulin, and the resident was rehospitalized for five days. Interviews with staff, the resident’s family, and the physician confirmed that the resident had been expected to receive insulin and blood glucose monitoring, but those orders were not implemented on admission and were not recognized until after the resident’s condition deteriorated.
Inadequate Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest practicable level of physical, mental, and psychosocial well-being for residents. The report specifically notes that staff were not adequately prepared to address the unique care requirements of all residents, which directly impacted the quality of care provided.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's actions or inactions regarding the required reporting process for such incidents. The report indicates that there was a delay or failure in notifying the appropriate authorities about the suspected event and in communicating the outcomes of the internal investigation as required by regulations.
Failure to Establish Ongoing Quality Assessment and Assurance Group
Penalty
Summary
The facility failed to establish an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. This inaction resulted in the absence of a systematic process for identifying, reviewing, and addressing quality issues within the facility. As a result, there was no documented evidence that quality deficiencies were being regularly reviewed or that corrective plans were being developed and implemented to address identified issues.
Deficiency in Managing Resident Funds
Penalty
Summary
The facility failed to properly manage and provide access to residents' personal funds, affecting two residents. Resident #32, who is cognitively intact, reported difficulties accessing his money for necessary purchases like phone cards. Despite having a significant balance in his account, he was repeatedly told that funds were unavailable, and he had not received his quarterly statements for at least six months. A grievance filed by him earlier in the year highlighted similar issues, but there was no evidence of resolution communicated to him. Resident #47, also cognitively intact, experienced a negative balance in her account, which she was unaware of until informed by the facility. She was accustomed to receiving regular cash withdrawals but was told her account was overdrawn by approximately $400. The facility continued to withhold her monthly allowance to cover this negative balance without obtaining her consent or signature. The Business Office Manager acknowledged the billing error and the lack of proper communication with the residents regarding their account statuses. The Business Office Manager explained that the facility's transition to a new company for handling checks had caused delays and cash shortages, particularly during high-demand periods like holidays. The facility's policy required cash to be available within one day of request, but this was not consistently met. The Activities Director confirmed delays in purchasing items for residents due to these financial management issues. The facility's failure to adhere to its own policies and ensure residents' access to their funds led to significant dissatisfaction and financial inconvenience for the residents involved.
Failure to Provide Homelike Dining Environment
Penalty
Summary
The facility failed to provide a homelike environment for residents dining in the B Wing dining room, as observed during meal times. On two separate occasions, residents were seen eating their meals in a setting that lacked homelike features. The tables were devoid of tablecloths or centerpieces, and the walls were bare without any pictures or posters. Additionally, there was no music playing, resulting in a very quiet atmosphere. Residents were served their meals on trays, which were not removed or arranged on the tables, and staff left the room after serving the trays. A Certified Nursing Assistant (CNA) confirmed that meals were delivered on a cart full of trays and served to residents in this manner. The CNA also acknowledged the absence of tablecloths and the usual silence in the room. The facility's Administrator later observed the dining room and admitted that it was not homelike and required improvement. The facility's policy on providing a safe, clean, and comfortable homelike environment was not adhered to, as evidenced by the observations and staff acknowledgments.
Improper Waste Disposal Due to Damaged Dumpster
Penalty
Summary
The facility failed to ensure waste was disposed of in a sanitary manner, as observed during a kitchen inspection. An uncovered dumpster was found at the back of the facility, with one lid missing and the other lid warped and half torn from the hinge, preventing it from sealing properly. This condition was acknowledged by the Certified Dietary Manager, who stated that the maintenance department was responsible for maintaining the dumpsters. The Maintenance Director confirmed the dumpster's condition, noting it had been like this for about two months and that the regional maintenance consultant was aware of the need for replacement. The Administrator was not informed of the dumpster's disrepair until the survey, and despite acknowledging the issue, the facility continued to use the dumpster due to a lack of alternatives. Observations revealed garbage bags containing food items, drink cans, plastic utensils, paper products, and adult briefs, with one bag torn open. The Food and Drug Administration's 2017 Food Code requires outside receptacles for waste to have tight-fitting lids, which the facility failed to comply with, potentially attracting pests and rodents.
Repeat Deficiencies in QAPI Activities
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee conducted effective performance improvement activities to sustain prior improvement measures. The facility had previously been cited for deficiencies at F584, F585, F694, and F814 during a recertification survey conducted in May 2023. However, during the current survey, the facility was found to be in noncompliance with the same deficiencies, indicating that the corrective measures were not sustained. The QAPI program was intended to be comprehensive and data-driven, focusing on indicators of care outcomes and quality of life, but it was identified that there was insufficient auditing and oversight to correct the deficiencies. The Administrator acknowledged that the QAPI committee met monthly and included staff from various departments to review and discuss data gathered by departments. Performance Improvement Plans (PIPs) were developed and implemented based on survey outcomes, and audits were part of PIP monitoring. Despite these efforts, the Administrator admitted that repeat citations were identified during the current survey, indicating a system breakdown that needed to be addressed. The goal of the QAPI activities was to make and sustain improvements, but the repeat deficiencies highlighted a failure in achieving this objective.
Inadequate Infection Control and Equipment Storage
Penalty
Summary
The facility failed to implement proper infection prevention and control measures, specifically regarding Enhanced Barrier Precautions (EBP) and the storage of resident equipment. Observations revealed that signage for EBP was incorrect or missing, and Personal Protective Equipment (PPE) was not readily available for residents on EBP. For instance, a resident on contact isolation due to a wound had incorrect signage and lacked appropriate PPE outside the room. The Infection Preventionist acknowledged these issues, noting that PPE was stored in a supply room rather than being accessible at the point of care. Additionally, another resident receiving gastrostomy tube feeding had no EBP signage or PPE available, highlighting a systemic issue in the facility's infection control practices. Furthermore, the facility did not adhere to proper storage protocols for resident equipment, as evidenced by the observation of unlabeled basins on the bathroom floor in a resident's room. These basins were not stored in plastic bags or labeled with the resident's name, which the Infection Preventionist and staff acknowledged as a breach of infection control practices. The facility's policy did not address the storage of resident equipment, contributing to the deficiency in maintaining sanitary conditions.
Failure to Maintain Resident Dignity During Dining
Penalty
Summary
The facility failed to maintain the dignity of two residents during dining. Resident #13, who has severe cognitive impairment and is dependent on assistance for all activities of daily living, was observed eating dessert by licking pudding and a frozen treat directly from the containers. This occurred because the built-up spoon provided was too large to fit into the dessert cups. No staff were present in the dining room to assist or observe the resident during this time. Resident #88, also with severe cognitive impairment, was left waiting for her lunch for 45 minutes while sitting at a table with another resident who was eating. A CNA mistakenly thought Resident #88 had already eaten and only realized the error after being informed. The delay was due to the kitchen running out of food and having issues with the oven, which resulted in a second portion of meals needing to be cooked. The Director of Nursing acknowledged that residents should receive their meals at approximately the same time and that staff should be present to observe residents while dining.
Failure to Evaluate and Document Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that two residents were properly evaluated for the safe self-administration of medications and did not obtain the necessary physician orders for self-administration. Resident #37, a female with intact cognition, was observed with a bottle of nasal spray on her tray table, which she self-administered. Despite her claim of being tested for competency, there was no documented assessment or physician's order for the nasal spray or for self-administration in her clinical records. Licensed Practical Nurse (LPN) A confirmed the absence of such documentation and acknowledged that the nasal spray should have been kept on the medication cart. Resident #95, also with intact cognition, was found with Vitamin B-12 and an empty container of Rosuvastatin in her bedside drawer. She self-administered the Vitamin B-12 daily but was unsure if the nurses were aware of it. A review of her clinical records revealed no physician's order or assessment for self-administration of the Vitamin B-12. LPN A stated that all medications, including over-the-counter ones like Vitamin B-12, should have a physician's order to prevent drug interactions and should be documented by the nursing staff. The Director of Nursing (DON) was informed of the findings, including the lack of physician orders and assessments for self-administration for both residents. The facility's policy requires an interdisciplinary team to assess the safety of self-administration and obtain a physician's order before allowing residents to self-administer medications. However, this protocol was not followed for the two residents, leading to the deficiency.
HIPAA Violation Due to Unlocked Computer Screen
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of a resident's medical records, resulting in a Health Insurance Portability and Accountability Act (HIPAA) violation. On January 16, 2025, at 10:20 AM, a computer on medication cart #1, located near the nurses' station on the A Wing, was observed with its screen open and facing the hallway. This allowed pertinent information regarding a resident to be visible to staff, residents, and visitors passing by. At 10:24 AM, RN F was present at the medication cart and stated that she had previously locked the computer screen before leaving the cart. However, at 10:29 AM, the Assistant Director of Nursing (ADON) confirmed that she had logged onto the computer to check the spelling of the resident's name and forgot to lock the screen when she walked away. The ADON acknowledged that this oversight constituted a HIPAA violation. The facility's policy, effective April 1, 2022, and revised on February 21, 2023, mandates that staff lock or log off computers when not in use to protect residents' personal health information.
Failure to Follow Grievance Process for Missing Personal Property
Penalty
Summary
The facility failed to adhere to its grievance process, resulting in a deficiency related to a resident's missing personal property. A resident, who was cognitively intact, reported losing her cell phone in her previous room. Despite informing staff and the Social Services Director about the missing phone, the facility did not document the grievance or make prompt efforts to resolve it. The resident had to purchase a new phone, which she could hardly afford, and was unable to communicate with her daughter for almost a month due to the missing phone. The Social Services Director, who was also the Grievance Officer, confirmed that grievance forms were available and that grievances were discussed in management meetings. However, the resident's grievance was not documented in the Grievance Log, and the Social Services Director only planned to write a grievance form after the resident provided a receipt for the new phone. The Social Services Director acknowledged that staff were expected to inform her of grievances, but this did not occur in this case. The B-Wing Unit Manager and a CNA were aware of the missing phone and had searched for it, but it was not found. The Unit Manager collected a witness statement from the CNA but did not complete a grievance form, assuming the Social Services Director would handle it. The facility's policy required grievances to be documented and tracked, but this process was not followed, leading to the deficiency.
Deficiencies in Resident Grooming and Hygiene Care
Penalty
Summary
The facility failed to provide adequate nail care and removal of chin hair for three residents, leading to deficiencies in their activities of daily living (ADL) care. Resident #13, who was severely cognitively impaired and dependent on staff for all ADLs, was observed with long, dirty nails while eating lunch. Despite having a care plan that directed staff to check and clean nails on bath days and as necessary, the resident's nails were neglected. RN I acknowledged the oversight, stating that CNAs were aware of their responsibility to maintain nail hygiene daily. Resident #88, also severely cognitively impaired and requiring substantial assistance with personal hygiene, was observed with long facial hair on her chin over several days. RN I confirmed that CNAs were expected to remove facial hair on shower days or when noticed, and the resident did not refuse care. Similarly, Resident #87, with moderately impaired cognition and dependent on staff for personal hygiene, was found with untrimmed nails and a dark substance underneath. CNA C admitted to not providing nail care despite the resident being in her assignment. The facility's policy required CNAs to maintain residents' grooming and hygiene, which was not adhered to in these cases.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities to meet the needs and preferences of three residents, as observed during a survey. Resident #13, who has severe cognitive impairment due to dementia and other conditions, was frequently observed in the day room or in her room without engaging in any activities, despite her care plan indicating a preference for music, going outside, and group activities. There was no documentation from the Activity staff indicating that activities were offered or declined by the resident. Resident #40, with moderate cognitive impairment and other health issues, was also observed lying in bed with no activities or television on, despite his care plan noting a preference for reading, music, and social activities. Similar to Resident #13, there was no documentation from the Activity staff about offering activities or the resident declining them. Resident #88, who has severe cognitive impairment and requires assistance with personal care, was observed multiple times in the day room and in her room without engaging in any activities. Her care plan indicated a preference for being outside, group activities, and music. The Activity Director acknowledged that activities were primarily conducted in the main dining room and that residents who self-isolated typically did not participate. The documentation provided by the Activity Director did not reflect any actual activities being provided to the residents, indicating a deficiency in meeting the residents' activity needs.
Failure to Ensure Timely Vision Care for Resident
Penalty
Summary
The facility failed to ensure a resident received timely treatment to maintain his vision, specifically for a resident with a history of type 2 diabetes, bilateral leg amputation above the knee, and glaucoma. The resident was cognitively intact and had been informed by his optometrist of bleeding behind his left eye, necessitating a specialist consultation. Despite multiple notes and orders from the optometrist and physician to arrange a retinal consult, the facility did not follow up in a timely manner. The resident eventually saw a specialist, but the delay in consultation may have impacted the effectiveness of the treatment. The deficiency was attributed to a breakdown in the facility's process for scheduling external appointments. The transportation and scheduler for residents' appointments explained that orders needed to be entered as verbal or telephone orders to appear on her report. However, several orders for the resident's retinal consult were entered as prescriber written, causing them to be missed in the scheduling process. This oversight was compounded by the expiration of a verbal order before it was acted upon. The facility's failure to ensure proper communication and follow-up resulted in a significant delay in the resident receiving necessary eye care.
Failure to Timely Change IV Dressing for Resident
Penalty
Summary
The facility failed to ensure the timely and appropriate administration of IV dressing changes for a resident receiving IV therapy. The resident, who was admitted with a history of MRSA infection and a current diagnosis of wound infection, was receiving IV antibiotics. The care plan required regular observation and changing of the IV dressing per physician orders and facility protocol. However, the Medication Administration Record (MAR) showed a lapse in documentation and execution of the dressing change schedule. Specifically, the dressing was changed on 1/03/25, but there was no documentation of a change on 1/10/25, and the next scheduled change was set for 1/17/25, indicating a potential 10-day gap without a dressing change. Observations and interviews revealed that the IV dressing was dated 1/07/25, and the Licensed Practical Nurse (LPN) confirmed that the dressing should have been changed on 1/14/25. The Director of Nursing (DON) acknowledged the oversight and the lack of documentation for an as-needed dressing change on 1/07/25. The Regional Nurse Consultant (RNC) identified an issue with the setup of the as-needed order, which prevented proper documentation of dressing changes. This deficiency in the facility's protocol and documentation process led to a failure in maintaining the resident's IV site as per the required schedule.
Failure to Implement Pharmacy Recommendations and Physician Orders
Penalty
Summary
The facility failed to implement pharmacy recommendations and physician orders, and did not document a physician rationale for not following pharmacy recommendations for three residents. Resident #61 had multiple medication regimen review (MRR) recommendations from the pharmacist that were either not responded to by the physician or agreed upon but not implemented. These included recommendations for dose reductions, discontinuations, and medication switches due to potential risks such as increased falls and improper medication administration. Despite the physician's agreement on some recommendations, changes were not reflected in the medical record, and no rationale was provided for disagreements. Resident #34, who was cognitively intact and had a history of falls, received several MRR recommendations from the pharmacist regarding medication adjustments to reduce fall risk and manage diabetes. The physician disagreed with all recommendations without providing a rationale in the medical record or the MRR report. This lack of documentation and implementation of pharmacy recommendations contributed to the deficiency. Resident #11's MRR included recommendations for proper administration instructions for Psyllium and evaluation of the need for sliding scale insulin. Although the physician agreed to these recommendations, the changes were not implemented in the resident's orders. The Director of Nursing acknowledged the issues with the MRR process, including the lack of rationale for physician disagreements and the failure to implement agreed-upon changes, which were attributed to high turnover among Unit Managers and the handling of the process by the Assistant DON and herself.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that a PRN order for a psychotropic drug, specifically Xanax, was limited to fourteen days for a resident. The resident, a male with a history of schizophrenia, psychosis, dementia, depression, seizures, and chronic kidney disease, had a physician order dated October 1, 2024, for Xanax 1 mg every 12 hours as needed for agitation. This order did not include a stop date, which is a requirement for PRN psychotropic medications. The facility's Director of Nursing (DON) acknowledged the absence of a stop date and stated that the medication should have been re-evaluated for continuation. Interviews with the A Wing Registered Nurse/Unit Manager and the DON revealed that PRN Xanax is typically prescribed for 14 days, and if used occasionally, it could be continued for 30 days. However, if not used, the medication should be discontinued. The facility's policy on administering medications did not address a stop date protocol for PRN psychotropic medications, but it did instruct that frequent PRN use should prompt a reevaluation by the Attending Physician and the Interdisciplinary Care Team. Despite these guidelines, the resident's medical record lacked documentation of a stop date or reevaluation for the Xanax prescription.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent a mentally impaired resident from exiting the facility unsupervised and did not provide adequate supervision and a secure environment. The resident, who had severe cognitive impairment and a history of elopement, was able to leave the facility through a window. The resident's medical record indicated he had multiple diagnoses, including osteomyelitis, type 2 diabetes with foot ulcer, cognitive communication deficit, and schizoaffective disorder. Despite being identified as an elopement risk and having an elopement alarm, the resident managed to exit the facility unsupervised. On the day of the incident, staff discovered the resident was missing and initiated a search. The resident was found walking on a busy road without shoes, wearing only non-skid socks. Interviews with staff revealed that the resident had been transferred to a new room the day before the elopement, and the window in this new room was not checked or secured. The Maintenance Director admitted that checking windows was not part of his daily inspections, and the window latch in the resident's new room was broken. The facility's policy on elopement and missing residents emphasized maintaining a safe and secure environment, but this was not effectively implemented. The staff failed to notice an increase in the resident's behaviors and did not increase supervision accordingly. The Administrator and DON acknowledged that the root cause of the incident was the failure to secure the resident's window and to recognize the need for increased supervision. The facility's assessment tool indicated that they were equipped to handle residents with psychiatric and cognitive impairments, but this incident demonstrated a lapse in ensuring the safety of such residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Merritt Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Solaris Healthcare Merritt Island | 0.4 mi | ★★★★★ | 0 | 0 |
| The Terrace At Courtenay Springs | 3.2 mi | ★★★★★ | 5 | 0 |
| Rockledge Healthcare & Rehabilitation Center | 4.2 mi | ★★★★★ | 0 | 0 |
| Sunrise Point Health And Rehabilitation Center | 4.4 mi | ★★★★★ | 2 | 2 |
| Viera Healthcare And Rehabilitation Center | 10 mi | ★★★★★ | 7 | 0 |
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