Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 The Terrace At Courtenay Springs during CMS and state inspections, most recent first.
The facility failed to maintain routine infection surveillance data and had no evidence of infection surveillance or data collection after records were lost during a power outage. The DON and Infection Preventionist acknowledged the lack of hard-copy records and the absence of surveillance data. The facility also used an inaccurate influenza consent form for 5 residents; the form incorrectly referenced PPSV instead of influenza, and the DON and Infection Preventionist confirmed the consents were not accurate.
Incomplete Care Plans for Elopement, Falls, and Oxygen Needs: The facility failed to develop comprehensive person-centered care plans for residents with identified elopement risk, fall risk, and respiratory needs. One resident with dementia and psychiatric diagnoses was observed moving through the unit without a wander alarm despite being high risk for elopement, another resident had an elopement order and high-risk evaluation but no care plan, a hospice resident with repeated falls had fall interventions listed without clear documentation of implementation or appropriateness, and a resident ordered continuous oxygen had no respiratory care plan despite inconsistent oxygen use and an incorrect flow rate setting.
Failure to Follow BP Management Orders: A resident with a history of aortic dissection/AAA repair reported that his surgeon and cardiology guidance required SBP to stay below 130, but the facility used a PRN clonidine order only when SBP was above 160. Records showed repeated elevated BP readings and staff notes documenting that the resident requested medication and expressed concern, yet no new orders were obtained despite hospital and cardiology recommendations for close BP control.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD: Four residents had documented PTSD with psychiatric notes describing trauma, nightmares, flashbacks, hypervigilance, and, in some cases, identified triggers. Although the MDS and EMR reflected PTSD and related mood diagnoses, the care plans did not include specific trauma-informed interventions or trigger-based approaches. Staff stated they relied on meds or behavior-related care planning, and acknowledged no trauma-informed care plans had been initiated for the residents.
The facility failed to prevent foodborne illness due to improper food storage and handling. An employee's lunch bag was found in the walk-in refrigerator above uncovered raw chicken and potatoes. The same employee attempted to store her lunch in the refrigerator again the next day. Additionally, a dietary server handled food with gloves, answered the phone, scratched her hand, and continued food service without changing gloves, violating the facility's policy on glove use.
The facility failed to submit timely MDS discharge assessments for six residents, with assessments over 120 days past due. The DON was unaware of the oversight, which was attributed to a transition to a new electronic medical record system. The MDS Coordinator confirmed the assessments were not submitted as required by federal and state guidelines.
The facility failed to provide SNF Advance Beneficiary Notices (ABNs) to two residents after their Medicare Part A stays ended. Both residents received Notices of Medicare Non-Coverage (NOMNC) but not the required SNF ABNs. Interviews revealed confusion between the Social Services and Business Office departments regarding responsibility for issuing these notices.
A resident self-reported neglect, stating they waited 30 minutes to be changed. The DON was informed and met with a DCF investigator, but the incident was not reported to the State Agency as required. The Social Services Assistant did not interview the resident or collect witness statements, and the NHA was unaware of the neglect allegation. The facility's policy required reporting within 24 hours, which was not followed.
The facility failed to provide written notification of hospital transfers for two residents. One resident with multiple diagnoses was transferred without written notice to their representative. Another resident, who was cognitively intact, was transferred multiple times for possible gastrointestinal bleeding, but only received verbal notifications. The facility's Social Service Director and Administrator acknowledged the oversight, attributing it to new staff members.
A facility failed to update a resident's PASRR after a new schizophrenia diagnosis was made. The resident was initially admitted with diagnoses including anxiety and depression, but a psychiatry evaluation later added schizophrenia, which was not reflected in the PASRR. The DON confirmed that the necessary updates were not made, despite facility policy requiring a PASRR Level II evaluation for new mental health diagnoses.
A resident at high risk of falls due to multiple health conditions fell out of bed, and the facility failed to implement a bolster mattress intervention for eight days. The delay was due to a lack of communication and follow-up among staff, leaving the resident at risk of further falls.
A resident with a Midline IV for antibiotic administration had a dressing that was not changed within the recommended 5-7 days, as observed in a facility. The dressing was dated eight days prior, and there were no orders for dressing changes in the medical records. The RN confirmed the oversight, and the facility's protocol for reviewing new admissions to ensure all orders were in place was not followed.
A resident was observed receiving supplemental oxygen without a physician's order, and the care plan did not include oxygen therapy. The MAR lacked documentation for oxygen administration, and interviews with staff revealed a failure to enter and monitor oxygen orders as required by facility standards.
The facility's QAPI committee failed to effectively implement Performance Improvement Plans, resulting in repeat deficiencies for failing to report abuse/neglect allegations, provide written transfer notices, and ensure kitchen sanitation. Despite previous corrective actions, these issues were identified again, indicating insufficient auditing and oversight.
Infection Surveillance and Influenza Consent Form Deficiencies
Penalty
Summary
The facility failed to establish routine, ongoing, and systematic infection surveillance to identify infections, infection risks, communicable disease outbreaks, and to maintain or improve resident health status. During interview, the Infection Preventionist stated she had been in the position for a year and described duties that included following residents on precautions, intravenous medications, staff education on infection control, monitoring residents on antibiotics, communicating with physicians about labs, and reevaluating as needed. On interview, the Infection Preventionist and the DON acknowledged there was no evidence of infection surveillance or data collection because everything was lost during a power outage in January, and they had no data to present. They also stated they did not have a binder with hard copies, and the DON did not clarify oversight of the Infection Preventionist. The facility also failed to provide accurate influenza consent forms for 5 of 5 residents reviewed for immunizations. Review of the influenza vaccine permission form showed the third option incorrectly referenced the Pneumococcal Polysaccharide Vaccine (PPSV) instead of the influenza vaccine. The Infection Preventionist and DON acknowledged the five influenza consents were inaccurate, stated the form had been used the entire time, and confirmed the residents did not have accurate consent signed. The Infection Preventionist stated she was responsible for reviewing the consents and did not realize the form was incorrect.
Incomplete Care Plans for Elopement, Falls, and Oxygen Needs
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans that addressed the medical, nursing, and behavior needs of 4 of 4 residents reviewed for comprehensive care plans. The report identified that the facility’s policy required care plans to include measurable objectives and timeframes to meet each resident’s medical, nursing, mental, and psychosocial needs, along with all services identified in the comprehensive assessment. In each of the reviewed cases, the resident’s assessments, orders, or documented events showed needs that were not reflected in the care plan. Resident #8 had diagnoses including schizophreniform disorder, schizoaffective disorder bipolar type, unspecified dementia, and generalized anxiety disorder, and was living on the secured memory care unit. An elopement evaluation identified her as high risk for elopement, and the MDS showed moderate cognitive impairment. She was observed entering and moving about the facility without staff accompaniment and without a wander/elopement alarm on her wheelchair or body. The comprehensive care plan did not include an elopement risk care plan, and the DON confirmed the resident was an elopement risk and should have had a wander/elopement alarm in place. Resident #59 had diagnoses including metabolic encephalopathy, acute kidney failure, and unspecified psychosis. Although the record included a physician order for a wander/elopement alarm and an elopement evaluation identifying him as high risk for elopement, the care plan did not address elopement risk. Resident #44 had diagnoses including alcoholic cirrhosis, dementia with behavioral disturbances, senile degeneration of the brain, brief psychotic disorder, blindness, and chronic pain syndrome, and was on hospice. He had documented falls, including being found on the floor next to his bed with a skin tear, and the care plan listed fall risk interventions such as bolsters and a hospice companion, but documentation did not show whether those interventions were initiated or remained appropriate. Resident #95 had diagnoses including a right femur fracture, acute respiratory failure with hypoxia, COPD, and CHF, and had an order for continuous oxygen at 1.5 LPM via nasal cannula. She was observed with the oxygen concentrator on, but the cannula was not connected and the flow rate was set at 2.5 LPM; her care plan did not address respiratory status, oxygen administration, or refusal of therapies.
Failure to Follow Blood Pressure Management Recommendations
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals for a resident with a history of aortic dissection, abdominal aortic aneurysm repair, heart failure, hypertension, type 2 diabetes, severe morbid obesity, and chronic pain syndrome. The resident reported that his cardiac surgeon instructed him to keep his systolic blood pressure below 130, but he stated the facility would not give antihypertensive medication unless his systolic blood pressure was above 160. He told surveyors that he had repeatedly informed the facility that blood pressure above 130 could be life threatening. Hospital records showed the resident was transferred for evaluation after an abnormal abdominal ultrasound and was found to have a type B aortic dissection with aneurysmal dilation up to 5.2 cm. The hospital documented that vascular surgery determined the dissection was likely chronic or residual from a prior aortic event and that no urgent intervention was required, with the plan that systolic pressure be kept under 130. Facility cardiology consultation also documented close blood pressure monitoring and maintaining systolic blood pressure below 130, and the resident had an order for PRN clonidine. Despite these recommendations, the resident’s physician order for clonidine was written as 0.1 mg every 6 hours PRN for systolic blood pressure greater than 160. Facility notes showed the resident had elevated blood pressures, including 175/88, 144/75, and 152/84, and staff informed him that clonidine was only ordered for systolic blood pressure above 160. When the resident expressed concern and requested medication, staff notified the physician or NP, but no new orders were given. The unit manager stated she was not aware before the resident raised concerns that hospital paperwork and the facility cardiologist recommended systolic blood pressure less than 130.
Failure to Develop Trauma-Informed Care Plans for Residents with PTSD
Penalty
Summary
The facility failed to identify and provide ongoing monitoring of known past trauma for four residents with documented PTSD. For each of the four residents reviewed, the record showed psychiatric documentation confirming PTSD and describing trauma-related symptoms such as nightmares, flashbacks, and hypervigilance, yet the care plans did not contain specific trauma-informed interventions or trigger-specific approaches to reduce re-traumatization. Resident #40 had diagnoses including alcohol abuse with alcohol-induced psychotic disorder, psychoactive substance abuse with withdrawal, major depressive disorder, anxiety, and PTSD. Psychiatry documentation described trauma from emotional abuse growing up with alcoholic parents and identified triggers such as slamming doors and yelling, with a care plan note directing staff to enter the room calmly, introduce themselves, and explain what they were doing. The resident’s MDS showed intact cognition, and the psychiatric/mood diagnoses included depression, anxiety, psychotic disorder, and PTSD. However, the care plan only addressed a general risk for mood problems related to PTSD, ADHD, and anxiety and did not include specific PTSD interventions or triggers. During interview, the resident described PTSD related to growing up in a military family and stated that slamming doors, yelling, and fire drills were triggers, and that he sometimes had nightmares and woke up yelling. Resident #4 had diagnoses including unspecified dementia, major depressive disorder, anxiety disorders, and PTSD. Psychiatry documentation again described a history of trauma with nightmares, flashbacks, and hypervigilance, and a psychiatrist note listed PTSD with a care plan note that identified no triggers and referred the resident to psychotherapy. The resident’s MDS showed moderate cognitive impairment, and the psychiatric/mood diagnoses included anxiety, depression, and PTSD. The care plan addressed mood distress, depression, anxiety, PTSD, insomnia, and dementia in general terms, but it did not include a specific PTSD care plan or triggers. In interview, the resident stated he did not have triggers or trauma and said it was a long time ago; he also stated he did not think he had PTSD. Resident #16 had diagnoses including major depressive disorder, anxiety disorder, alcohol abuse with intoxication, persistent mood disorder, and PTSD. Psychiatry documentation described trauma-related symptoms and noted that the resident could not identify specific triggers. The resident’s MDS showed intact cognition and active psychiatric/mood diagnoses including anxiety disorder, depression, psychotic disorder, and PTSD. The care plan addressed psychotropic and antidepressant use and listed diagnoses including persistent mood disorder, insomnia, anxiety, brief psychotic disorder, and PTSD, but it did not contain a specific PTSD care plan or trigger-based interventions. Resident #49 had diagnoses including schizophrenia, alcohol abuse, epilepsy, unspecified dementia, anxiety disorders, adjustment disorder with depressed mood, and PTSD. Her MDS showed severe cognitive impairment and an active PTSD diagnosis with anti-anxiety medication use. Psychiatry documentation identified PTSD with trauma-related symptoms, but the comprehensive care plan only addressed general mood distress and depression with counseling and problem-solving interventions and did not specifically address past trauma or triggers. In a meeting with the DON, MDS Coordinator, Administrator, and Social Services Director, staff stated that psychiatric diagnoses were added to the EMR and that care plans were initiated based on medications or behaviors, and they acknowledged that no trauma-informed care plans had been initiated for the four residents.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to store and serve food in a manner that prevents foodborne illness, as observed during a survey. During an initial tour of the kitchen, a lunch bag belonging to an employee was found on a shelf inside the walk-in refrigerator, above containers of raw chicken in marinade that were not fully covered, and near uncovered cubed potatoes. The Food Service Director acknowledged that personal items should not be stored in the refrigerator and that food containers should be covered to prevent contamination. Despite this acknowledgment, the same employee was observed attempting to store her lunch bag in the refrigerator again the following day, indicating a disregard for proper food storage protocols. Additionally, during a tray line observation, a dietary server was seen handling food improperly. The server wore gloves while handling plates, answered the phone without changing gloves, and scratched her bare hand with a gloved hand. She then resumed plating food without cleaning her hands or changing gloves, and handled unwrapped rolls with the same gloves. This behavior was not corrected by any supervisor, as none were present in the kitchen at the time. The facility's policy on preventing foodborne illness states that gloves are single-use items and must be discarded after each task, which was not adhered to in this instance.
Failure to Submit Timely MDS Discharge Assessments
Penalty
Summary
The facility failed to complete and submit discharge assessments in a timely manner for six residents, as required by federal and state guidelines. The Minimum Data Set (MDS) assessments for these residents were over 120 days past due. Specifically, the facility did not complete or submit MDS discharge assessments for residents who were either discharged or had expired. This included residents who were admitted and later discharged or expired, with no MDS discharge assessment or death in facility tracking record completed or submitted. The Director of Nursing (DON) was unaware of the missed MDS assessments and attributed the oversight to a transition to a new electronic medical record system. The MDS Coordinator confirmed that the required assessments were not submitted within the required timeframe. The facility's policy stated that the assessment coordinator was responsible for ensuring timely completion and submission of resident assessments, but this was not adhered to in these cases.
Failure to Provide SNF Advance Beneficiary Notices
Penalty
Summary
The facility failed to provide the appropriate notices of financial liability to two residents who were reviewed for Skilled Nursing Facility (SNF) Beneficiary Protection Notification. Resident #50, diagnosed with Parkinson's disease, protein-calorie malnutrition, hypotension, and mild cognitive impairment, began a Medicare Part A skilled nursing stay on January 1, 2024, with the last day of coverage on March 8, 2024. Although Resident #50 received a Notice of Medicare Non-Coverage (NOMNC) at the end of the Medicare Part A stay, they did not receive a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). Similarly, Resident #54, with diagnoses including traumatic ischemia of muscle, rhabdomyolysis, hypertension, cognitive communication deficit, and polyneuropathy, began a Medicare Part A skilled nursing stay on March 1, 2024, with the last covered day on March 8, 2024. Resident #54 also received a NOMNC but did not receive a SNF ABN. Interviews with the Social Services Director and the Business Office Manager revealed a lack of clarity and communication regarding the responsibility for issuing SNF ABNs, resulting in no SNF ABNs being issued for these residents.
Failure to Report Alleged Neglect to State Agency
Penalty
Summary
The facility failed to report an alleged violation of neglect to the State Agency as required for a resident who self-reported neglect. The resident, who was cognitively intact, reported having to wait 30 minutes to be changed. The Director of Nursing (DON) was aware of the situation and forwarded the information to the Nursing Home Administrator (NHA) and Social Services, but the incident was not reported to the State Agency. The DON met with a Department of Children and Families (DCF) investigator and law enforcement, but the facility did not proceed with the required reporting. The Social Services Assistant, who was the Abuse Coordinator, did not interview the resident on the day of the report and failed to collect witness statements. The NHA stated he was not informed of the neglect allegation and did not recall receiving the email from the DON. He acknowledged the facility's failure to report the allegation and was waiting for the DCF report's determination. The facility's policy required such allegations to be reported within 24 hours to the State Agency, which was not adhered to in this case.
Failure to Provide Written Notification of Hospital Transfers
Penalty
Summary
The facility failed to provide written notification of transfer to the resident or their representative for two residents who were hospitalized. Resident #25, who had multiple diagnoses including multiple sclerosis and chronic obstructive pulmonary disorder, was transferred to the hospital with altered mental status. Despite the transfer, the facility could not provide documentation of written notice to the resident or their representative, as confirmed by the Social Service Director. Resident #15, who was cognitively intact, was transferred to the hospital multiple times for possible gastrointestinal bleeding. Although the resident's daughter was verbally notified of the transfers, the facility failed to provide written notification. The Social Service Director acknowledged that only two of the Notification of Transfer or Discharge forms were signed by the resident, and there was no proof that the forms were provided to the resident or mailed to the representative. The Administrator noted that the process fell through the cracks due to new staff members.
Failure to Update PASRR Following New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to ensure the Preadmission Screening and Resident Review (PASRR) was accurately completed following a new mental health diagnosis for a resident. The resident was admitted with diagnoses including type 2 diabetes mellitus, cognitive communication deficit, unspecified dementia, anxiety, and depression. The initial PASRR form completed prior to admission listed anxiety disorder and depressive disorder, with dementia as a secondary diagnosis. However, a subsequent psychiatry evaluation revealed a new diagnosis of schizophrenia, which was not updated in the PASRR form. The resident's medical record indicated a history of chronic and consistent psychosis and past suicide attempts, which were not reflected in the PASRR update. Despite the facility's policy requiring a PASRR Level II evaluation for new or changed mental health diagnoses, no updates were made to include the schizophrenia diagnosis. The Director of Nursing confirmed that the Admissions department was responsible for initial PASRR completion, while the DON and unit managers were tasked with ensuring accuracy and handling necessary updates, which were not performed in this case.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident who was at high risk of falls due to multiple health conditions, including spinal stenosis, blindness, muscle weakness, and cognitive impairment. The resident, who was dependent on staff for mobility and transfers, fell out of bed, as observed by a CNA. Despite the care plan being updated with an intervention for a bolster mattress to prevent falls, this intervention was not implemented for eight days following the fall. The delay in implementing the bolster mattress intervention was due to a lack of communication and follow-up among the facility's staff. The Central Supply Coordinator was not informed of the need for a bolster mattress until eight days after the fall, despite the intervention being discussed in IDT meetings and documented in the care plan. The ADON, responsible for ensuring the implementation of fall interventions, did not follow up to confirm the intervention was in place, leading to the resident remaining at risk of further falls.
Failure to Change Midline IV Dressing as Per Protocol
Penalty
Summary
The facility failed to ensure the timely change of a Midline intravenous (IV) dressing for a resident, which is a deviation from professional standards aimed at preventing infection. The resident, a female with a history of sepsis, urinary tract infection, metabolic encephalopathy, and chronic obstructive pulmonary disease, was admitted with a Midline IV inserted. The dressing on the Midline IV was observed to be lifted at the edges and dated eight days prior, indicating it had not been changed within the recommended timeframe of every 5-7 days as per the facility's policy. The oversight was confirmed by the Registered Nurse responsible for the resident's care, who acknowledged the absence of dressing change orders in the electronic medical records. The facility's protocol required the clinical team to review new admissions to ensure all necessary orders were in place, including those for IV dressing changes. However, this protocol was not followed, as evidenced by the lack of orders for the Midline IV dressing change, which should have occurred the day before the observation.
Deficiency in Safe Oxygen Administration
Penalty
Summary
The facility failed to ensure safe supplemental oxygen administration for a resident, leading to a deficiency in respiratory care. The resident, a cognitively intact female with multiple diagnoses including shortness of breath, was observed receiving supplemental oxygen via a nasal cannula at a flow rate of 3.5 liters per minute without a physician's order. The resident's care plan did not include supplemental oxygen therapy, and there were no documented physician's orders for oxygen in the medical record. Additionally, the Medication Administration Record (MAR) lacked documentation entries for oxygen administration, monitoring, or tubing changes. Interviews with nursing staff revealed that nurses were responsible for entering physician's orders and monitoring supplemental oxygen administration, which should have been recorded on the MAR. However, the resident had been receiving oxygen therapy without proper documentation or orders. The Director of Nursing confirmed that the facility's standards required physician's orders for oxygen administration and regular monitoring, which were not followed in this case. The oversight in entering and monitoring oxygen orders led to the deficiency in providing safe respiratory care for the resident.
Repeat Deficiencies in Reporting, Transfer Notices, and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee effectively implemented Performance Improvement Plans to address and monitor previously identified deficiencies. During the last recertification survey conducted on November 9, 2022, the facility was cited for deficiencies at F609 for failing to report abuse/neglect allegations, F623 for failing to provide written notice of transfer to residents who were transferred out of the facility, and F812 for failing to ensure kitchen sanitation and cleanliness. Despite the QAPI committee's approval of a Plan of Correction on December 29, 2022, which included monitoring corrective actions to prevent recurrence, these deficiencies were identified again during the current survey. The repeat citations for F609, F623, and F812 indicate that there was insufficient auditing and oversight of the concerns identified in the previous citations. The Nursing Home Administrator (NHA) explained that the QAPI committee worked on identified deficiencies for periods ranging from 90 days to 6 months, performing audits and discussing findings during QAPI meetings. However, the NHA was under the impression that the repeat deficiencies had been corrected, suggesting a gap in the effectiveness of the QAPI committee's monitoring and corrective actions.
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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) |
|---|---|---|---|---|
| Sunrise Point Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 2 | 2 |
| Rockledge Healthcare & Rehabilitation Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Space Coast Healthcare And Rehabilitation Center | 3.2 mi | ★★★★★ | 0 | 0 |
| Solaris Healthcare Merritt Island | 3.7 mi | ★★★★★ | 0 | 0 |
| Viera Healthcare And Rehabilitation Center | 7 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.